Workforce Planning in the Health Sector: Discussion

The purpose of the meeting is to meet Medical Council representatives to get an insight into and examine workforce planning in the health sector. We will hold two sessions on this topic, the first with the Medical Council and the second at 11.30 a.m. with the Irish Hospital Consultants Association, IHCA. On behalf of the committee, I welcome Mr. Bill Prasifka, chief executive officer, CEO, of the Medical Council; Dr. Rita Doyle, president; and Ms Janet O'Farrell, research manager.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, they 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. I advise witnesses that any opening statements they make may be published on the committee's website after the meeting.

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 invite Dr. Rita Doyle to make her opening statement.

Dr. Rita Doyle

I thank the committee for this opportunity to address it today.

The Medical Council is the statutory body responsible for the regulation of doctors within the Republic of Ireland. The council works to ensure that medical education, training and lifelong learning is benchmarked against the highest international standards. Standards for undergraduate and postgraduate training are set by the council while we also require doctors to maintain their professional competency through updating and maintaining their professional skills on an ongoing basis. The 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. Fitness to practise inquiries and complaints are dealt with in accordance with rules, fair procedures and direction from the courts. In summary, the key objective of the council is to protect the interests of the general public in its interactions with registered medical practitioners while also supporting these doctors.

As the council’s register is a valid and complete list of doctors who are legally permitted to practise medicine in the State, it is a comprehensive source of medical workforce intelligence. Following the 2016-17 workforce intelligence report, which was launched in April this year, we published the medical workforce report for 2018 last week. This included a deep dive into the data describing demographics of those retaining and withdrawing from the register of medical practitioners in 2018 to inform workforce planning and, ultimately, improve patient care and safety in Ireland.

There is a continued overreliance on foreign-trained doctors, as evidenced by the continued increase in the general division of the register. The practical and cultural challenges within the health system need to be addressed in tandem with an increase of appropriate health practitioner supply, otherwise, these problems will escalate.

A year-on-year decrease in applicants to the register was observed between 2016 and 2018. Simultaneously, the number of those who voluntarily withdrew their registration between 2014 and 2018 increased year on year with a net flattening impact on the register. Comprehensive and co-ordinated workforce planning is necessary to determine requirements to put the right doctors in the right place with the right qualifications.

The research findings establish that while we train a significant number of doctors, this needs to increase to ensure we have a sustainable medical workforce into the future. Ireland has been replacing the doctors in the system rather than changing the system itself, which is notable through the feedback received from doctors leaving the register. We need more attractive working conditions and increased opportunities to enter medical training programmes to guarantee substantial, high-quality workforce recruitment and retention, both short-term and long-term.

Our recruitment and retention challenges have now filtered right through from service posts to retention of consultants in the Irish context. We know that we are experiencing doctor shortages.

This is being managed through high-cost interventions, for example, the use of locum services, and this impacts on the continuity and quality of patient care. Examining retention is crucial to producing a sustainable self-sufficient workforce into the future.

In 2018, there were 2,190 doctors who enrolled on the Medical Council register for the first time. That is the figure for new entrants to the register. The primary growth reported was in the general division of the register. Most new entrants to the register were in the general division and educated outside of Ireland. Doctors from countries outside of the EU cumulatively contributed more new entrants to the Irish register of medical practitioners than Ireland. Non-consultant hospital doctors, NCHDs, were the most prevalent group of doctors registered with 7,800 on average in the system, an increase of 6.6% since 2017. Some 46.1% of NCHDs were in training while the remaining 53.9% occupied non-training posts.

A total of 20,109 doctors with an average age of 44.5 years chose to retain their registration. Some 86.9% of these doctors were on the general and specialist divisions of the register. The majority of those retaining their registration were male and were Irish graduates. It was also self-reported that for every two hospital consultants there were three NCHDs on the register. Approximately 70% of non-retaining doctors were aged 44 or under. Some three quarters of non-retainers were on the general division and 24% were on the specialist division.

In 2018, there were 1,453 voluntary withdrawals recorded, representing a 37.9% increase since 2017. One third of doctors who left the register of medical practitioners in 2018 were graduates of Irish medical schools. This group comprised slightly more female, some 52%, than male doctors. Most of these doctors reported leaving the general division of the register while 29% left the specialist division. Interns represented 11.9% of this group leaving the register. The majority of these doctors planned to practise medicine in another country while 66 doctors planned to stop practising altogether. For those who left due to workplace issues, resourcing and lack thereof was cited. However, the lack of appreciation and value placed on the work and perseverance of doctors in such circumstances was a contributing factor. The consequent personal impact of excessive hours and lack of support also raised significant challenges not only to morale but to patient safety as well. Most registrants who reported leaving due to limited career progression planned to pursue available opportunities in the United Kingdom. In particular, the UK was cited as a jurisdiction that welcomed doctors and was willing to support and train them. Respondents reported accessing a training scheme as a significant barrier to career progression. The standards set for admission to schemes was perceived as variable, compared to the international context.

For those educated internationally or possessing international experience, gaining employment at consultant level in the specialist division in Ireland was reported as a significant challenge as well. This reflected recruitment and retention challenges at the most experienced level of the medical career trajectory. In total, 320 doctors reported leaving the register for family or personal reasons. International graduates from a medical school outside the EU and Ireland made up half of this group, while medical practitioners who graduated from a medical school in the EU and were EU nationals comprised an additional quarter of this group. The majority of respondents leaving due to family or personal reasons were leaving the general division of the register. However, a little over one in five doctors leaving the register for these reasons were specialist registrants. Some of those leaving explicitly cited the incompatibility of long working hours with the demands of family life. Family members and their care across the lifespan was a strong theme that emerged from the qualitative data reported, as would be expected in this category. In particular, maternity leave was cited ten times in the data. The demands of balancing both home and medical professional practice was made explicit by one respondent, who noted the challenges that the long working hours present. Supporting spouses in their careers was also cited as a reason for leaving the register by respondents.

Through evidence-based data-driven reporting, we can provide this continuing national picture of the medical workforce in Ireland. We can identify trends, highlight areas of concern and make suggestions on how to address issues. Findings from this report and other research conducted by the council highlight continued trends and concerning insights that need to be addressed collaboratively by policymakers, educators, planners and employers to effect meaningful change to support doctors and, most importantly, to protect patients.

I thank Dr. Doyle. I call Deputy Stephen Donnelly.

I thank the Medical Council representatives for attending, their opening statement and their great work on the report. For nerds like me there are loads of facts and figures to get stuck into. Am I correct that, in 2016, a total of 948 doctors voluntarily left, in 2017, the figure increased to 1,054 and, in 2018, it increased to 1,453?

Dr. Rita Doyle

That is correct.

It increased from approximately 950 to 1,050 to nearly 1,500. There was a substantial increase last year .

Dr. Rita Doyle

Yes, it was a 36.9% increase on the previous year.

Dr. Doyle is also a nerd. The obvious question this raises is whether this was a statistical blip. Is it because of some structural issue? Is there a perfectly reasonable explanation for such a vast increase in those leaving or is this a signal of something more serious such as a tipping point in the system with more doctors leaving at an exponential rate?

Dr. Rita Doyle

Ms O'Farrell may wish to comment.

Ms Janet O'Farrell

Yes, I can answer that. I am also a nerd. With these numbers, we can see some of the changes. There were introductions of professional indemnity and increasing demand relating to continuing professional development, CPD. That is cited in the voluntary withdrawals in the qualitative data on a small scale, but not on a scale that would reflect that change or explain it. The rates have increased over time fairly solidly. If we look back to 2014, we can see the rate of withdrawals was 546. Over time, the figure has gone up and up. We do not have a final figure this year because we look at it from 1 January to 31 December, but certainly the trends this year are reflective of what was reported last year. We are seeing broad trends again this year.

That is not a statistical blip. The figure has gone from 550 steadily and rapidly upwards. In four years, we are at three times that figure. For every doctor who was leaving four years ago, there are now three doctors leaving.

Ms Janet O'Farrell

Yes.

Mr. William Prasifka

There is a trend of increasing voluntary withdrawals and it is unmistakable. We had identified this as being a problem. That is why in the past two years we have been asking doctors who are withdrawing to give us their reasons. Anyone in the survey business of doctors knows that is not easy to do. We conduct surveys of trainees and if we can get 15% to 20% to respond, we consider it to be a success rate. For the past two years for doctors voluntarily withdrawing-----

Dr. Rita Doyle

The figure is 76.9%.

Mr. William Prasifka

Before then it was two thirds. That tells me these doctors have a story they want to tell. It is the combination of the increase of voluntary withdrawals, which is highly significant, with the qualitative data that our research manager can take committee members through. Together they tell a consistent story to the effect that there is deep dissatisfaction with the practice of medicine for many of our most highly trained graduates. This is replicated in other surveys done by other institutions.

This is deeply worrying. We have a shortage of doctors in this country.

Dr. Rita Doyle

We already have a shortage of doctors.

We are more than 40% below the European average. We have the lowest level of hospital consultants per capita in the developed world. For every doctor who was leaving four years ago, there are now three doctors leaving.

Dr. Rita Doyle

They are only the ones we know about. We certainly know of graduates abroad who do not withdraw from the register because they think they may come back. It is more than that - that is the point I am making.

Dr. Doyle is probably very well placed to have a view on the top two or three issues. Obviously there are many issues and I imagine she could cite 100 different ones. From the data she has seen and the interviews the Medical Council of Ireland has conducted, are there two or three outstanding issues that are driving this very worrying increase in our doctors leaving?

Dr. Rita Doyle

Ms O'Farrell would have the exact figures but I would say that contrary to what people think, it is not all money. There is the resource issue. The fact that entrants to the consultants' register are being paid one third less than their colleagues is an issue but it is not the main issue. It is the culture in which medicine is practised in this country that is the main issue.

Could Dr. Doyle say more about that?

Dr. Rita Doyle

Doctors are abused, I would think. They are made to work far longer hours. We would not let a pilot fly forever but there is no limit to the number of hours consultants can work. Doctors report bullying in the workplace; certainly among the younger doctors between 40% and 50% report bullying in the workplace. I listen to the young doctors. The interns in particular worry me terribly because they do not even have a job description. Their current job description is that they do what nobody else will do. These are the cream of our graduates. These are the people with high intellects and they are thrown into this system and are absolutely exhausted. They talk about bullying, lack of respect and the absence of any good work-life balance.

It sounds horrific and it certainly matches what I and, I imagine, all the members of this committee have heard. It is deeply stupid as well in terms of trying to run a world-class public healthcare system. That toxic culture that Dr. Doyle has just described - who would want to work in that or come up through it? Is that a facet of medicine internationally or is it a facet of medicine in Ireland?

Dr. Rita Doyle

I think it is a facet of medicine in Ireland. Many of our graduates go to the UK but a lot of the younger graduates are going to Australia and New Zealand. They are reporting back to us that they have a much better work-life balance and that they are respected. There is a deep lack of respect for doctors, for some reason, in this country.

Given that we are not particularly mean or nasty people relative to our American or Antipodean cousins, what is it about the Irish public healthcare system that is causing this? Is the same toxic culture reflected in private practice in Ireland, in the private hospitals?

Dr. Rita Doyle

I cannot answer the Deputy's second question. We do not have specific data on people who are in private or public practice. I suppose medicine was always a hierarchical career. The consultants are under huge pressure. I am not blaming them because they are not doing all the bullying but I think that the circumstances in which they work, the lack of respect from HR - as long as I am around, young doctors have been in training that changed every six months or every year, yet at least 20% of them are put on emergency tax twice a year. It is just stupid. These are young people who have to pay their rent and feed their kids but they get very little support from HR. That is part of it.

Why does Dr. Doyle think that is particularly a problem in Ireland as opposed to other countries? Other countries appear to have been able to modernise their HR and other systems. Why have we not been able to do that in Ireland?

Dr. Rita Doyle

I think that is a question more for the HSE than for me. I am not involved in HR but I hear the stories from the doctors of how badly they are treated. Somebody said to me last week that when a doctor in Ireland gets a phone call from HR, he or she shakes. This doctor's daughter was doing her general practice in Australia. The daughter said that when she got a phone call from HR she was absolutely shaking but they just rang to know how she was getting on and had she made the change all right. It is a different culture.

I thank Dr. Doyle. The reason I was asking her as opposed to the HSE was that I am not entirely sure we would get a full and frank answer from the HSE. Around particular pinch points, the Medical Council's data does some very useful gender analysis as to men and women leaving the system. It is interesting to note that there are quite significantly more female trainees. There are more women going into the doctor training pipeline yet at the top there are significantly fewer. That could be for historic reasons, meaning that as the younger cohort grows older it will balance out. However, it could be for structural reasons, namely that we have a system that is structurally even less friendly to women. What is Dr. Doyle's view on that?

Dr. Rita Doyle

I think I had a bit of a light bulb moment about that recently. We never made any planning for the feminisation of medicine. When I went through training I was in a class of 120 and there were only 18 women, so it was not feminised. Now it is nigh on equal with about 48% women and 52% men. I do not think that any plans were made for the fact that women have children. The stage at which they are just finishing their higher specialist training or their general practice training is often the time when they have children. No allowance is made for that. No extra allowance is made for people who are going to take maternity leave. The workload falls on the people who are there. Mothers have to pick up their children from crèches. I hear senior consultants saying, "where is that one gone, she is gone to pick up her children?" Of course she is gone to pick up her children, she is a mother, what else would she do? There are no allowances for the feminisation of general practice. That needs to be looked at. There should be supernumerary interns, senior house officers, SHOs, and registrars at every level so that when somebody goes on maternity leave or her child gets sick or whatever, there is somebody to step in and the workload is not doubled on her co-intern or her co-SHO.

Dr. Doyle also talks about geography. Something like 43% or 46% of those leaving were from Dublin. I do not imagine 46% of the doctors in the country are registered in Dublin.

Dr. Rita Doyle

No.

Clearly there are more leaving from Dublin than other areas. I am delighted to see Wicklow did not show up. Who would want to de-register in Wicklow? It did not show up in the data, the numbers were so small. Are there particular geographies? Why is Dublin being hit so badly along with maybe Galway, Cork and others? I do not think it is in the data but has the Medical Council of Ireland gone down to hospital-by-hospital level? Are there hospitals which we can identify as being particularly bad for the retention of doctors?

Ms Janet O'Farrell

We do not collect specifics on hospital sites, unfortunately. That is the nature of data collection for the register. It is not necessarily verifiable employment data so we do not look at that. The HSE would have better figures on that and has done some analysis of it, I understand. There is a lot of movement in Dublin, as we can see. I think through the voluntary withdrawals qualitative data we can get a sense of some of that. On the Deputy's previous question about the reasons for moving, the first is family and personal reasons. Dr. Doyle talked about that. Limited progression opportunities are another reason. We have a lot of non-consultant hospital doctors, NCHDs, based in Dublin, those in training and not training. Proportionately the number of those in training has decreased in relation to the number who are not in training. The numbers who are not in training have increased over the past three years by about 800. There are real challenges in that group in progressing on to training and career progression. About four in five or 80% of them are international medical graduates and have a real challenge getting onto a programme that will further their career. In a situation like that, a doctor is going to make a sensible choice to want to progress his or her career and will look elsewhere to do that, so many of them do leave. They are in service provision posts and unfortunately currently, under the legislation, there are real challenges in that. The proposed amendments to the Act that are proposed would provide for more equity of access for those doctors, which could address the matter. That is something we would really like to see progressed.

Dr. Rita Doyle

If I could just put a rider on that, it should improve their access to training but there has not been an increase in the number of training places so it will increase competition for training. It will be fairer to the non-Irish NCHDs who are not in training but it will produce competition.

Unless the numbers of places for training are increased, therefore, it will not be of any value.

I thank the witnesses for attending. I would not describe myself as a nerd but I understand work and industrial relations because that is the way I made my living for a while. I will get on to those matters fairly quickly but page 1 of the witnesses' statement refers to fitness to practise inquiries and the way complaints are dealt with in accordance with rules and fair procedures. I refer briefly to a case that was highlighted over the weekend and another case highlighted recently in newspapers in Donegal. I refer specifically to the case of Jim Kenny and his now deceased wife, Eileen, and I have Mr. Kenny's permission to do so. I do not propose to dwell on the case. However, Mr. Kenny believes, and it was very clear from the documentary, that the Medical Council let his wife down inasmuch as it-----

This meeting is about workforce planning.

I understand that.

It is not to deal with any other issues.

I referred specifically to a matter that was raised in the witnesses' opening statement. It is my intention to follow up this case with the Minister. I have one question to put.

I remind the Deputy that only issues connected with the subject matter of these proceedings are to be raised.

I understand that. The witnesses may decline to answer. I have one question with regard to the issue of fair procedures. It relates to where someone can go following a complaint being received.

The issue the Deputy is raising is not the subject matter of the meeting.

The issue was raised in the opening statement.

I cannot allow the Deputy to ask that question because it does not relate to the purpose of this meeting.

I believe the Chairman is being unfair but I will not pursue the matter because I do not wish to be vexatious or contentious. I will pursue the matter, however. We will stick to issues of workforce planning. That is fair.

Dr. Doyle indicated that the average age of doctors is 44.5 years. Is the average age increasing?

Ms Janet O'Farrell

It varies according to group. The average age of general practitioners, GPs, in practice is 50 years. The figure varies across the board but we can dig down into the figures if the Deputy is interested in specifics.

I am most interested in GPs. I am conscious that there is a very young GP in the room with us, although I am not referring in any way to the Chairman. I had a friend who used to say averages tell us nothing because if one puts one foot in a bucket of ice and the other in a bucket of boiling water, on average, one's temperature will be fine. However, in this instance, the averages or trends tell us a good deal. I am curious to know if there are specific specialties or areas where a problem may arise that is caused not just by the failure to recruit but also by the ageing population of the relevant cohort.

Ms Janet O'Farrell

I do not have the figures in front of me but my understanding is that the average age in the area of public health is also quite high. That is not to say that 50 is old but it is above the average of the full cohort of doctors. Our plan for the next report is to dig into these age profiles further but if the committee wants more specific information on age, it will not be a problem providing it.

That would be helpful, if only to inform where we need to direct efforts to try to address the issue. Clearly, if the average age among a particular cohort is increasing, it would indicate a problem in a particular area.

Dr. Doyle indicated that doctors believe they are not adequately appreciated and valued. As I said, I am not a nerd but I know something about work. Nothing says I value and appreciate someone more than cold, hard cash. Are there other mechanisms that can be employed at this time? It is clear that there is an issue. We can point to money, which is a very serious issue and one doctors are raising, but there are other issues also. Are there measures that can be taken in the short, medium and long term? If there is an immediate crisis, we should be in a position to be able to address it. What short, medium and long-term measures, in addition to providing money, can be taken to address this issue in some way?

Dr. Rita Doyle

There is no doubt that we need at least another 500 consultants in the short term to get us back to where we were ten years ago. I do not believe increased resilience training is of any benefit at this stage. If a piece of elastic is stretched too far, it will eventually break. I have no doubt that our workforce has reached that point. It is in crisis.

I share that view. It does not matter how many training courses are put in place.

Dr. Rita Doyle

Absolutely.

If someone cannot get protected time to attend a training course, there may as well be 50 courses running per week because if someone cannot attend, that person cannot benefit. It is all down to capacity and recruitment.

Dr. Rita Doyle

I will give the Deputy a very good example of that. We like to respond to complaints and the biggest complaint is around communication. We have been talking to the HSE and the continuing professional development, CPD, people about delivering communications courses. The HSE runs a very good, structured communications course. It is led by Peter Gillen, a retired surgeon from Drogheda, and Winnie Ryan, a staff member of the HSE, and is now on module 5. It was agreed that this course should be part of the training programme for interns. The course takes three hours but no hospital will allow interns to take three hours off work.

We are still in breach of the European working time directive on a daily and weekly basis for non-consultant hospital doctors, NCHDs.

Dr. Rita Doyle

Absolutely. It is appropriate that they do the communication training but they will not be allowed off for three hours.

The course is offered but-----

Dr. Rita Doyle

The interns are mandated to take it but they cannot do so because of work conditions.

It is not that they do not want to take it. The course is being offered but they are not being facilitated to take time off. We are on a merry-go-round if we keep landing back at the same place, namely, recruitment.

Dr. Rita Doyle

It is bums on seats, yes.

Dr. Doyle referred to the issue of graduates going abroad. Graduates, particularly doctors and nurses who have a qualification that makes them highly mobile, like to go abroad for a year or two and see the world before returning. My information, which probably tallies with that of Dr. Doyle, is that doctors and nurses are leaving and getting a glimpse of what it is like to work abroad. They are also shown some of the appreciation and value they are not shown here and are then choosing to stay abroad. Dr. Doyle referred to doctors on the register who are practising abroad. She will not necessarily know the figures but does she have any sense, even as a percentage, of the numbers involved?

Dr. Rita Doyle

I am contacted personally about this type of thing and I suspect we could add another 10%. That is a guess.

I fully appreciate that it is a guess. I just wanted to get a sense of the numbers involved.

Dr. Doyle referred to the culture in which medicine is practised and the fact that no limit is applied to the hours worked by consultants, GPs or NCHDs. This applies across the board.

Dr. Rita Doyle

I am a general practitioner in the latter end of my career. I started work on Monday morning at 8 o'clock and finished at 10.30 p.m.

The level of burnout will cause an acceleration in the increase in the average age of doctors. It will push up the figure of 44.5 years even further because younger people are not entering the profession to bring that average down.

Dr. Rita Doyle

No.

The change in culture must be led from the top. Those who know something about the world of work will tell us that when staffing levels are low, it becomes extremely difficult for every person working in the health service, not just doctors.

Dr. Rita Doyle

Absolutely.

I believe that is a major contributory factor to the toxic culture Dr. Doyle has described. I would not want my daughter to work in those circumstances or in that environment.

Dr. Rita Doyle

Does the Deputy want to be looked after by doctors who are under that pressure?

There are 1 million people on waiting lists and some of them probably believe it is better to get into hospital. Dr. Doyle is right, however, that it is not an environment for patients or workers. The issue here is the failure to recruit. We will be talking to doctors' representatives after this session and again next week. I contend there is an issue around money. In the short term, nothing other than recruitment will make anything possible.

If I hear Dr. Doyle correctly, it almost does not matter what is done. We can lay on as many courses as we like but if staff cannot attend them if they do not get protected time. We can have all the well-being initiatives we like but if staff cannot get ten minutes off to eat a sandwich, they will not get an hour off to do mindfulness. That is no disrespect to mindfulness, which is probably great if one has the time. The study backs the view that without recruitment the resolution of these issues will not be possible.

Dr. Rita Doyle

The bottom line is that Ireland is an unattractive medical workforce environment. It is unattractive because of all of the issues Deputy O'Reilly and I have highlighted. That culture will not change until more bodies are put in. Everybody is stretched, from the bottom to the top of the health service.

I thank Dr. Doyle.

I am disappointed that the Chairman did not allow Deputy O'Reilly to ask her question, although I respect his ruling, even if it does not look good coming from a doctor.

If Deputy Kelly reads the statement read out at the start of every meeting-----

I understand that.

The rules are that the witnesses are invited in to give evidence on the matter that we have outlined to them in their invitation.

Yes. One of the issues I will raise is exhaustion among consultants and working hours that are not acceptable. Errors happen because of this. I must be honest in saying that. Consultants are human beings. They have worries and concerns about malpractice as a result of it. That is a real issue. I think the issues are related, and while I do not agree with it, I accept the Chairman's ruling. It does not look great to the public following these proceedings.

I am not showing any favouritism or bias in my ruling.

I did not say that.

The Deputy implied it when he referred to me being a doctor.

I often refer to the Chairman as Dr. Harty. In fact, I never refer to him as Deputy. That does not insinuate anything. I will not question the witnesses on this, but I will make a statement to which I do not want any response. I know of other cases apart from the one covered in the documentary.

I will not allow Deputy Kelly to refer to that case.

I will deal with it this way. I know many people in the medical profession. There is a concern among doctors that their workload and the number of hours they work result in malpractice, accidental or otherwise. Is that a fair assumption?

Dr. Rita Doyle

We know that doctors who are overtired or upset or who have been bullied have an increased risk of adverse events. We know that from the training council and, conversely, we know that if there is an adverse event, there is also an increased risk of bullying.

That is a fair point. I was not as conscious of the second point, which relates to bullying, but as Dr. Doyle has repeated it I am aware that it as a concern. On that basis, is it fair to say that the Medical Council will have to deal with issues that are referred to it due workload and exhaustion?

Dr. Rita Doyle

Is Deputy Kelly trying to relate our complaints process to the workforce?

No, what I am asking is whether Dr. Doyle believes the number of issues the Medical Council has to deal with is increasing as a result of the way in which consultants are treated in the workforce. If she does not believe that, then it does not correlate.

Dr. Rita Doyle

Complaints have been at a static level over the past three years, at 440. It looks this year as if it will be at the same level.

It looks like the complaints process will have to be changed. I will address that point to the Minister. A volte-face will be needed after what has been revealed. I am concerned. There are two ways of looking at this, either as a deep concern or as a good thing. We do not have enough consultants and they are overworked and overstretched. The hours they are working are insane, as are the conditions in which they work and the way many of them are treated, yet the number of complaints referred to the Medical Council is static.

Dr. Rita Doyle

Yes, the numbers have been much the same over the past three years. There is very little difference.

That is very interesting because it means there is no correlation between public concerns about malpractice and the conditions consultants work in and related factors. The absence of a correlation shows consultants must be working at a maximum level or close to the edge as otherwise there would be an increase in complaints.

Mr. William Prasifka

We should remember there are 23,000 practitioners on the register and we average between 350 and 450 complaints per annum. That is a very small percentage of complaints. Just as an example, in a previous life, when I was Financial Services Ombudsman, we would get more than 10,000 complaints a year. I know that is comparing two different things.

They are completely different.

Mr. William Prasifka

Yes. What I am saying is that when one has such a small number of complaints, I do not think one can draw many conclusions between complaints to the Medical Council and adverse events. Let us remember that a complaint to the Medical Council focuses on the fitness to practise of a doctor. There is no compensatory scheme. It is not a scheme of redress, so it does not give the same insight into total adverse events that other types of complaints regime would have. That is all I am saying.

Yes, it is interesting that the statistics have flatlined, despite the fact that we all know we have fewer consultants proportionately than we had some years ago. The figures have been flatlining for a number of years. That says an awful lot for the consultants. It is a good thing and a good statistic. I am not sure if people are aware of that because to be honest, I was not aware of it.

I will ask a few questions based on the statistics provided. I do not know if the witnesses will be able to answer all of them. Is there a breakdown for the consultants that are leaving, by discipline and area? In what area is the highest percentage of consultants leaving?

Ms Janet O’Farrell

When we collect the data, we do not collect information on the specialty.

Why not? That information would be very useful to us.

Ms Janet O’Farrell

I agree that it would be helpful. Within the qualitative material, doctors sometimes report the areas, in particular those on the specialist division. Our GPs often tell us that they are GPs.

If I could make a suggestion, could the Medical Council change its qualitative research process and collect that information? It would be very interesting to know what disciplines people are leaving.

Ms Janet O’Farrell

Yes. With the questioning structure, the original figure of close to 550 would have been a small number of doctors leaving. Proportionately, one would not necessarily be able to get great trends out of that on an annual basis.

One would over two or three years.

Ms Janet O’Farrell

Now that are figures are much larger, capturing that would be much more helpful and we would be able to see more trends in that now.

In three or four years' time, we would have trend analysis. We have to start somewhere.

Ms Janet O’Farrell

Yes, absolutely.

From a qualitative point of view, what is the gut feeling on the disciplines specialists are leaving?

Dr. Rita Doyle

I think a lot of them are general practitioners. We are very short of general practitioners. I train young doctors and three of my former registrars are in Australia at the moment and there is another one in Canada.

I believe that is probably accurate. I am also interested in statistics on geography. Do we know where the consultants and doctors who have left the system are working? Do we have a breakdown of that information?

Ms Janet O’Farrell

No. The questionnaire is a much more brief the one we send out at retention. It does not look at geography or specialty. What it looks at are the division of registration and the reasons for leaving, which are explored and people have space to report to us what that looks like. We can go back through the registration numbers and see where people have previously reported that they have worked. It is possible to do that. It is a little messy but it can be done. We can do that if Deputy Kelly wishes.

Would Ms O'Farrell mind providing that information?

Ms Janet O’Farrell

We will do our best.

Would it also be possible to change the inputs to gather that information in the future?

It will be very useful to know, from a geographical perspective, the facilities such people left, the final posts they held and their specialties. That information is incredibly important to us; we are talking about it all the time.

The Medical Council does not distinguish between public and private. The geographical spread of access to private practice in Ireland is interesting. For example, in the mid west, the area in which myself and Dr. Harty live, essentially, there is no private hospital. We have the former Barringtons Hospital in Limerick but there is no fully private hospital. The level of private practice in certain disciplines in University Hospital Limerick, UHL, is among the highest in the country. There are options in other areas such as Galway, Cork and Dublin. Is there any correlation between doctors and consultants leaving practice and their access and attitude towards private versus public practice?

Dr. Rita Doyle

We do not have any data on that.

Does Dr. Doyle have a gut feeling about it? We now know that consultants are on two-tier contracts. That is an issue we have talked about ad nauseam and most of us are on the same page in respect of it. Is access to an opportunity to practise privately a variable to be considered for medical practitioners who are deciding to leave the country?

Dr. Rita Doyle

It certainly has not come up in our qualitative data. I know of three or four consultants who have left the public sector here and gone to work in private medicine in this jurisdiction. Lack of access to private facilities has not appeared in our qualitative data.

We all know that the conditions in which many consultants work are unacceptable although it is not the same across the various hospitals. Those of us in the mid west know there is a particular issue in UHL that is incredibly bad in comparison with the position in Beaumont Hospital. The number of doctors per head of population in Beaumont versus UHL is a national scandal. Doctors in UHL are working in insane conditions.

We obviously need an influx of consultants. We also need to change their conditions, remuneration packages and numerous other things. I have always been of the belief that hospitals need to turn into seven-day working institutions. Have we any analysis as to how that would go down with doctors?

Dr. Rita Doyle

I do not have any information on that.

Does Dr. Doyle have a gut feeling? I am asking a lot of questions because the quantitative and qualitative data that has been provided does not seem to provide a lot of answers. Hopefully it will do so in the future.

Dr. Rita Doyle

My gut feeling is that patients get sick every day of the week and every minute of the day, so a seven-day system is logical.

That is a good and welcome statement. I thank Dr. Doyle.

I thank our guests for attending and I appreciate the contributions they are making to the health service in monitoring and supervising the medical practitioners. I wish to ask a question arising from Dr. Doyle's presentation and relating to an article on thejournal.ie. Dr. Doyle stated that a "year-on-year decrease in applicants" registering was observed between 2016 and 2018. Articles were written in a number of newspapers that gave the impression that the number of doctors registering in Ireland has gone down, whereas the figures between 2014 and 2018 show an increase from approximately 19,000 to in the region of 22,000. That was an increase of 20.72%. Nowhere did Dr. Doyle make reference to that and, as a result, newspapers have got the impression that there has been a reduction in the number of doctors working in Ireland. Is there not an obligation on the Medical Council to ensure true and accurate figures are given out? That is not what was given or what was picked up by the media.

Ms Janet O'Farrell

The report includes all of those figures.

In the release that went out to the newspapers, the impression was given that the number of doctors registering in Ireland had decreased. In no place in her presentation did Dr. Doyle refer to the increase other than in the accompanying graph. A false impression has been given out to the media that the number of doctors registering in Ireland has gone down, whereas it has gone up by 20.72%. At no point did Dr. Doyle refer to that.

Ms Janet O'Farrell

My understanding is that any of the press releases that went out would have included copies of this document.

Does the Medical Council have an obligation to make sure that people are not getting concerned about the number of doctors who are registering here? A false impression was given out that the number of doctors registering in Ireland has gone down where, in fact, it has gone up by 20.72%. Is that correct?

Ms Janet O'Farrell

That is correct.

The figures in the graph are correct. There were 19,049 registered in 2014 and there are now 22,996.

Ms Janet O'Farrell

Yes.

Are those the correct figures?

Ms Janet O'Farrell

Those are correct.

Would the Medical Council not correct that in the media? The impression is being given that there has been a drop in the number of people who are registering in Ireland.

Dr. Rita Doyle

There is a drop in the number of new registrants.

Dr. Rita Doyle

May I finish, please?

Dr. Rita Doyle

There has been a drop in the number of new registrants applying, so that graph is trending downwards while the number of withdrawals is going up. When those trends cross, there will be very serious-----

The Medical Council is giving the impression that the total number of registered doctors has gone down since last year. In actual fact, the number of people who registered in the quoted year was more than 2,000 and the number who left the profession was 1,400. The information released to the press is misleading in that the impression has been given that there has been a drop in the total number of people on the register which is not correct.

Ms Janet O'Farrell

I am sorry if there has been any misunderstanding of the material that went out.

That is a misunderstanding by the media. The number of people on the register has actually increased.

Ms Janet O'Farrell

It has.

It even increased from 2017 to 2018.

Ms Janet O'Farrell

The number of new entrants has declined and our concern is that, because of that decline and the increase in the number of voluntary withdrawals, the rate of growth on the register has slowed. It was to that rate of change we referred. We would not say that the number of doctors has declined because that is not true.

If one gives negativity, it creates negativity. The negativity given in the statement from the Medical Council created the impression that the number of people on the register is dropping and that is not correct. The number has increased by 20.72% in the past five years.

I want to move on to another issue.

Dr. Rita Doyle

Just to add one point on that, the new registrants are in the wrong division of the register to resolve the problem.

I know that, but the numbers have increased by 20.72%. It would be helpful if correct information was given out so there is not a false and misleading impression being given. I saw comments on thejournal.ie. Someone had quoted the initial figures the Medical Council had given and then gave the number of new registrations and someone made a comment that the article deserved a grade D.

Dr. Rita Doyle

It deserved what?

It is important that correct information is given out.

Dr. Rita Doyle

We certainly have not given any inaccurate information.

From whom can the Medical Council take complaints? I know of a situation where an adult patient did not file a complaint but his or her parent did. There was no reference to whether or not the parent had the authority to file the complaint. Is it acceptable that a complaint was taken from a parent? The patient was an adult and perfectly competent but the consultant concerned had to go through the whole legal process in dealing with that complaint even though it was not filed by a patient.

Dr. Rita Doyle

Does the Chair want me to answer that?

Yes, please.

Dr. Rita Doyle

Any member of the public can make a complaint. If the patient on whose behalf the complaint is being made is over 18, no information will be got without that patient's consent, full stop.

Dr. Doyle is incorrect. This person had to go through the legal process because it was a parent-----

Dr. Rita Doyle

No information will be got about that case until the patient gives consent, full stop.

The patient did not file the complaint.

Dr. Rita Doyle

A mother can file the complaint.

Dr. Doyle is saying that a parent is entitled to file a complaint, even though-----

Dr. Rita Doyle

Anybody can file a complaint. Senator Colm Burke can file a complaint about the treatment the Chairman, Deputy Harty, got in hospital but nothing will be done unless the Chairman gives his permission to have that complaint investigated.

However, the council is still putting the medical practitioner through the process even though it is not the patient who is filing the complaint.

Dr. Rita Doyle

The law is that any member of the public may make a complaint.

It is an unusual process-----

Dr. Rita Doyle

It is still the law.

It is an unusual process whereby the patient is not filing the complaint but a third party is doing so.

Dr. Rita Doyle

That is the law. It is the Medical Practitioners Act 2007 - I am sorry.

The third issue relates to litigation levels. Has the Medical Council looked at the issue of litigation? I will give two examples of-----

The subject matter of this morning's meeting is workforce planning.

I accept that but the litigation issue is related. The reason I am giving it is as an example of people who have dropped out. It is a very simple question.

The issue we are discussing is workforce planning.

It is related to why people are dropping out of the system. That is the reason I am raising it.

The Senator can ask in general, not specific, terms.

I am not asking any specific question. I am simply referring to a situation where two people dropped out of obstetrics and gynaecology. One of them had nine years training and the other six. They dropped out because of the stress levels and also because of the amount of litigation. What has been done in other jurisdictions that we could do here in order to give more reassurance to the people working here that they have the support of the system? One of the problems here is that people are dropping out of the system and leaving Ireland because they feel they do not have sufficient support. What could we do here to give more support to the people on the front line that has been done in other jurisdictions?

Dr. Rita Doyle

Litigation is not our area of expertise. We have nothing to do with litigation. I know, as a practitioner, that we live in a litigious society. The main reason people are leaving, if one looks at our qualitative data, is because of the culture within the health system.

I am asking what we can do to assist people. The council has looked at the position in other jurisdictions. What kind of action could be taken here in order to give more support to the people who are on the front line? What action has been taken in other jurisdictions?

Dr. Rita Doyle

What sort of support is the Senator talking about?

I am talking about support and reinsurance. Where a procedure goes wrong and there is no negligence, people are traumatised and there is a question of whether there is enough support within the hospital structure. I wonder if we could do a lot more in that area.

Dr. Rita Doyle

I do not think that has anything to do with workforce planning. The open disclosure project within the HSE should ease the system for doctors, as well as for patients.

What about the support that needs to be given to doctors who are on the front line?

Dr. Rita Doyle

I cannot answer that question. It is outside our expertise.

Surely, if the Medical Council is trying to attract people into this area, it should also be looking at how we can make the work-life balance better. Having looked at other jurisdictions, what is missing in Ireland that we should be doing and that is being done in other jurisdictions?

Dr. Rita Doyle

What is missing is the number of doctors.

It is about support as well.

Dr. Rita Doyle

I have said it already. I do not think increasing resilience and that type of thing is what is needed. We need more doctors and that is the first thing that will start to reduce the level of stress within the profession.

We also need give support to people who are on the front line. Does Dr. Doyle not accept that?

Dr. Rita Doyle

That goes without saying.

It also involves dealing with people who have come through a traumatic experience when dealing with a patient. I am asking if there are enough supports within our hospital structure to give people time out in regard to their-----

Dr. Rita Doyle

No, there are not enough supports. We know from Your Training Counts that doctors who are involved in adverse events feel very isolated and unsupported. We know that.

What can we do about that? That is what I am asking.

Dr. Rita Doyle

All we can do is bring it to the attention of the employer.

Having looked at other jurisdictions, is there something we do not have in Ireland that we should have - and that is available in other jurisdictions - in order to give that support?

Dr. Rita Doyle

I hope the new open disclosure will help in that area.

I welcome our guests. Reference was made to the issue of culture. Will our guests define the culture and those aspects of it that are discouraging in terms of retaining staff or encouraging to new registrants?

Dr. Rita Doyle

From our qualitative data, we find it is not family-friendly and not woman-friendly, and people are so busy they do not have time to stop. They are reacting to emergencies all of the time.

It is suggested that women are the majority of those who are forced out of the system, and working conditions were referred to in that regard. Bullying was also referred to. Who does the bullying and to whom?

Dr. Rita Doyle

The doctors are bullied mainly by consultants, but not always - it is about 56% - and then it is by nurses, by the general public, by patients and, occasionally, by GPs, some of whom may, perhaps, harass young doctors over the phone. Of course, hospital administrators are also in there.

To what extent does Dr. Doyle see that as central to the issues that cause doctors to drop out of the system?

Dr. Rita Doyle

I think it is very important. I would not stand around to be bullied; I do not know if the Deputy would.

He certainly would not.

Dr. Rita Doyle

I have listened to doctors who have been bullied and know that the effect on them as they think and as they go through life is quite serious.

Has any action been taken? Has anyone remonstrated with the bullies in these cases?

Dr. Rita Doyle

A lot of it is not reported. They report it to us but they do not do anything about it. I have spoken to the young doctors and interns who have just started and are about four months in the job. I have told them that bullying should be reported and that if they do not get satisfaction within their hospital, they could come to us and we would deal with it.

Bullying in the workplace is quite a serious issue generally and is not necessarily restricted to the health services. Is it not taken that seriously within the health services or as seriously as it is in other walks of life?

Ms Janet O'Farrell

I will refer to the HSE figures on bullying. When we look at the Your Training Counts survey, our rate of bullying was 41% in our most recent report. Across the HSE, the rate is 42% so it is reflective of a broader health culture and there are real challenges across the services. I know they are trying to address that and the Department was looking at trying to address it across the organisation, as vast as it is. Certainly, it is reflective of the broader health services culture. It is not just doctors.

The council regards it as a serious internal issue that requires attention.

Ms Janet O'Farrell

Absolutely.

With regard to new registrants coming from abroad and those from Ireland, to what extent do they have similar experience of bullying? It should be an interesting statistic.

Ms Janet O'Farrell

We asked questions about bullying in Your Training Counts. That survey is carried out across the board in respect of trainees - those on training schemes at the postgraduate level. It is a slightly different group.

When we look at that group, four or five of them are Irish graduates. It is primarily an Irish graduate group. It is difficult to dig down into it because they are over-represented within that group, as compared to the picture across the full register, which is different.

We had one person and one situation where information was given to us about an instance of bullying that drove the person to leave the workplace and where this was the primary reason for leaving. That was an international graduate. At trainee level we are not necessarily seeing those differences but the number of international medical graduates within that survey is very small.

Dr. Rita Doyle

That is because they do not have access to training.

Ms Janet O'Farrell

Exactly.

On working conditions, is there evidence in respect of modern hospital equipment, procedures and practices? Has a comparison been made or has this been observed in Ms O'Farrell's research? Is that a consideration for new registrants to look elsewhere or to leave after a short time?

Ms Janet O'Farrell

No. What is cited on the sites are challenges with resourcing, staffing and working with human resources. Those are the key things. People refer to the buildings they are working in but not necessarily to the equipment. Anecdotally we have heard that but it has not come through in the research thus far.

Would Ms O'Farrell identify working conditions as the biggest single reason - she said at the outset it was not always money - for people leaving?

Dr. Rita Doyle

It is work-life balance.

This is one of the issues that we have already discussed.

Have the investigations come across particular instances of bullying that were above and beyond what would be acceptable and what action, if any, was taken as a result?

Dr. Rita Doyle

I cannot answer that, as it is a question for the HSE. Young doctors are very scared to report this. They do not want to be whistleblowers, feel that their careers might be affected and are very slow to report it. I have been talking to them to say they must report it and have it dealt with from the very beginning.

This is my last question. There is a constant call for extra expenditure in the health services. Quite an amount of extra money has been provided to them, even in the current year. When a comparison is made with other OECD countries, we are in the top group as to expenditure. Why are we so close to the top in expenditure and also so close to the top in dissatisfaction levels with the delivery of the health services?

Dr. Rita Doyle

The money is being spent in the wrong places. We need to start investing in people and to look at alternative ways of managing our health service and moving more back into primary care and following the Sláintecare review.

That is happening in any event at present. To follow up, have the witnesses seen any evidence that new or aspiring registrants are impressed with that or do they see it as a reason for taking a new look at the Irish health service?

Dr. Rita Doyle

Are they impressed with what?

Are they taking a new look at the Irish health service with a view to becoming employed within the sector?

Dr. Rita Doyle

Is this because of Sláintecare?

Yes, because of Sláintecare.

Dr. Rita Doyle

I do not believe that new registrants have any idea what Sláintecare is about.

Does Dr. Doyle not think that it might be helpful if they did?

Dr. Rita Doyle

This is a report from this Government, is it not?

Dr. Rita Doyle

Is it not a cross-party report?

It is the report of a specific all-party committee of the Houses of the Oireachtas, which is representative of all shades of political opinion in this country-----

Dr. Rita Doyle

Yes, that is correct.

-----and maybe none. There is not much sense in producing a report of that nature, which is deemed to be integral to the running of the health service in future and taking into account all of the issues that we have dealt with and having received complaints about and going to all that trouble if, within the system, those directly involved in the front line say they do not know about it, as the Government or somebody else has produced it and it is not ours. It is, in fact, and is something that is there for health delivery services to take on board and deliver upon.

The reason I am labouring this point - I have stated that this was my last question - is that we cannot continue forever in this country spending more and more money. Dr. Doyle has said that the money is spent in the wrong places. I am quite certain that if I went in to examine the health services in the morning, I would find 50 people, at least, who would say that the money is being spent in the wrong place and there would be 50 different places.

I would like to see a greater interest in the practitioners becoming involved and having a pride in the delivery of the public health services. We have lacked that for quite a long time in this country and it is in everybody's interest that we take it up. Otherwise, we would be better off outsourcing it entirely and allowing somebody else to provide the services elsewhere because we cannot do it ourselves. There is no good in saying that we cannot do anything. We are highly priced and supposed to be efficient, effective and highly qualified. We need to be delivering.

Dr. Rita Doyle

I agree.

I thank Deputy Durkan and Dr. Doyle.

We will move now to Deputy O'Connell.

I thank all of the witnesses for coming in this morning and for the work that they do, which is to safeguard public health and to ensure that standards are correct.

On the reasons-for-leaving element of the survey, was it a tick box or was it a fill-it-in-as one-desires section on the form? How were the data analysed? Was there a written explanation as to why they left or was it a choice of one of five?

Ms Janet O'Farrell

Both were included by us. More people use the tick box than give us longer qualitative answers but a significant portion do.

It was mentioned that of the 23,000 practitioners registered, the level of complaints has remained static over the past three years. Do we have a larger picture, because the shedding of consultants from the Irish system started in 2008 to 2009, roughly speaking? Have we a picture of the past ten years rather than the past three years? What I am trying to get at is that as many consultants started to leave around that time, for all of the reasons given, was there any correlation between the shedding of Irish consultants from the system and a subsequent rise in complaints? Are there data to suggest that or do the witnesses have data to hand? Was there any peak?

Ms Janet O'Farrell

I only have data on the three years to hand but we report it our annual reports every year. We have not looked at any correlations because the number of complaints is rather low in proportion to the number of doctors on the register. It would be possible, however.

Dr. Rita Doyle

The enactment of the new Medical Practitioners Act 2007 gave other reasons, other than professional misconduct, for findings to be made against doctors. This would confound the figures.

The research gives no figures then for professional misconduct for-----

Dr. Rita Doyle

We have those figures but we do not have them to hand.

Those would be interesting to see if - there is no "if" about it, it is a fact - where doctors left, there was a gap then in the service and if there was a subsequent rise in-----

Dr. Rita Doyle

In complaints.

I am trying to find out about the impact on patients. The State Claims Agency last year paid out €3 billion, which I believe is the figure reported to the Committee of Public Accounts, 90% of which was medical-based. Without using the phrase "dumbing down" but if there is a reduction in standards, is that having a subsequent impact on State claims?

Last week, the committee discussed with the HSE the issue of the 108 doctors who are not on the specialist register. How does the Medical Council feel about the 108 doctors working out there who essentially do not meet the highest standard they should be meeting?

Mr. William Prasifka

The Medical Council is very concerned about that for a number of reasons.

Specialty recognition is given to doctors who have gone through significant training. This is deemed to be important for them to operate at the level at which a consultant should operate. It is also concerning because it is quite apparent to us that the HSE is not hiring these people because it wants to hire them; it is hiring them because it cannot find anyone else. It also tells us the important story that there are some positions that are no longer attractive for specialists to work in. This is concerning.

I have heard anecdotally that the concentration of this 108 cohort is in specific regional hospitals. I did not mention them last week and I will not mention them this week. I assume the council has looked at this. If 20 of the 108 are in a particular hospital, surely it is an issue of concern. Whose job is it to track the impact on patient outcomes?

Mr. William Prasifka

That information is within the HSE. The Medical Council regulates doctors; we do not regulate hospitals.

Has there been a spike in complaints that we can directly correlate to the 108? Is there a subsequent impact on patient care from the cohort that is not at the highest standard?

Mr. William Prasifka

One of the reasons this matter has come to public attention is confirmation hearings in the High Court arising from complaints. For a sanction to be effective, it must be confirmed by the High Court so there is a confirmation hearing. Complaints arose about particular doctors who were consultants. In one case, the President of the High Court noted a particular consultant was not on the specialty register and raised a great deal of concern about it. The simple fact is we are concerned about it. We are concerned about any diminution of standard. It would not be fair for us to say there was a spike in complaints but the reason we are speaking about this is complaints were made and it was brought to the attention of the President of the High Court and, therefore, it has become a subject of public focus. We have been working with the HSE through its national doctors training and planning unit. It has been looking at the problem and trying to identify it. It has been trying to put in place mechanisms so that doctors receive the correct training and are eligible to be put on the specialty register. We are anxious to work with the HSE in a way that does not diminish standards.

How is that going? If there were 108, are there 106 now? Is it going in the right direction? Is the training group having any impact on the level of quality?

Mr. William Prasifka

It would be better for the HSE to give this answer. I would say a lot of effort has been put into it. When the effort was initially begun we looked at the problem more intensely and it uncovered more consultants who were not on the specialty register. This does not mean the problem is getting worse; it means we are uncovering the scope of the problem. There has been progress in getting some of those doctors registered on the specialty register because it is determined by the Medical Council that they now meet the standards. Progress is being made but it is slow.

I will go back to the point made by Senator Colm Burke because I want to make sure I understand it. The graph shows a 20% increase in doctors registered but there is a reduced number of new entrants. Does this mean people who qualify are leaving without ever going on the register? Is that the point? What is the mix? Where are they coming from? If they do not come from new entrants are they just people landing in from somewhere else?

Ms Janet O'Farrell

The numbers we have reported show that new entrants on the register are decreasing. We have increasing voluntary withdrawals. The rate of interest of those who have come on the register has been declining since 2016. The rate of change has slowed significantly. It has not been steadily 20% over the years. They are often restorals to the register, where somebody has voluntarily withdrawn-----

Where they have gone off for a few years.

Ms Janet O'Farrell

They have gone off and they may come back but there is a cyclical pattern. Our colleague, Niamh Humphries, is carrying out research, of which the Deputy will probably be aware. She has spoken to doctors in Australia and is looking to survey doctors based in hospitals in Ireland. She is looking at cyclical patterns of movement among doctors going abroad, coming back, perhaps pursuing training and leaving again. She is looking at what this looks like and the impact on the health service.

Has it not always been the case that people have left and gone to Canada, trained and come back?

Ms Janet O'Farrell

Yes.

Looking at the figures, is it more pronounced now?

Ms Janet O'Farrell

It appears to be and through voluntary withdrawals, there seems to be reporting of moving in a more permanent way.

Regarding registration, there is practising registration and non-practising registration for pharmacists. Does the Medical Council have only one register?

Ms Janet O'Farrell

Yes.

What is the fee per year to register?

Dr. Rita Doyle

It is approximately €600.

I thank the Deputy.

I have one more question. Is the Medical Practitioners Act 2007 fit for purpose? I would like an honest answer. Is there anything we can do to improve outcomes for patients? Based on some of the commentary, does it need work?

Dr. Rita Doyle

Absolutely.

Are there any indicators Dr. Doyle might give us?

Dr. Rita Doyle

We have been waiting nine years for the new amendments that we hope will come through.

Does Dr. Doyle feel that when those amendments are applied, it will mean better outcomes for patients and, perhaps, for clinicians?

Dr. Rita Doyle

Absolutely.

The absolute number on the medical register is close to 23,000. How many are full-time equivalents? Dr. Doyle referred to the fact there is a greater number of people on the register but not the right type of people or the right ratio of people. I ask her to elaborate.

Dr. Rita Doyle

Too many NCHDs are not in training. Most of these are non-Irish qualified doctors and I have a moral issue with this. Without them, our health service would collapse but we are taking these doctors from countries that probably need them more than we do such as Pakistan and Sudan.

The number of people on the register-----

Dr. Rita Doyle

The number on the general register has increased but not the specialist register.

What proportion of NCHDs are not in training?

Dr. Rita Doyle

I believe it is just over 50%.

Ms Janet O'Farrell

It is over 50%. The number of NCHDs not in training is 53.9%.

Effectively, they have no career progression.

Dr. Rita Doyle

Absolutely no career progression. Even with amendment to the Act whereby they may be enabled to access training, they will be in competition with everybody else because the number of training places has not increased.

If they are not in training, they are not likely to stay here in the long term.

Dr. Rita Doyle

One of the comments from someone withdrawing from the register was that we will have them to work but we will not train them.

We invite people to work in Ireland-----

Dr. Rita Doyle

We invite workers.

-----but we are not giving them any opportunity to train.

Dr. Rita Doyle

Absolutely correct.

Is this a contributing factor to those doctors leaving?

Dr. Rita Doyle

I think so. Absolutely.

With regard to full-time equivalents, how many of the 23,000 people on the register are working at all? Are many doctors on the register not working?

Dr. Rita Doyle

There certainly are some retired doctors who have decided to stay on the register. They have to do their annual CPD. They may be working in teaching younger doctors but they are not clinically working. That is another percentage.

They do not provide a clinical service.

Dr. Rita Doyle

Yes.

Ms Janet O'Farrell

Approximately 83% work full time.

I can provide the committee with a more detailed breakdown. Certainly more than 80% are working full-time. Let us say that 12% are working between ten and 20 hours a week.

What is the number of doctors on the register who are not in Ireland? I refer to those who retain their registration.

Dr. Rita Doyle

We do not know. That is a guess figure. I would estimate that it is approximately 10%.

So 10% of 23,000 doctors may not be practising in Ireland.

Dr. Rita Doyle

Exactly.

Ms Janet O'Farrell

When we last looked at the data in 2018, we had 16,235 reporting active in clinical practice in Ireland.

Dr. Rita Doyle

The Chairman is talking in general about the register, not just-----

Ms Janet O'Farrell

It is in the region of 10%.

In the context of the GPs who have GMS numbers, how many are working full-time?

Dr. Rita Doyle

As the Chairman knows, the contract is full-time. They do not have part-time contracts. A doctor has to sign a contract to work 24-7, 365 days a year. However, he or she may not be working all those hours and may be sharing the role. There is no room for part-time general practice in this country.

Yes, the contract is 24-7, 365 days a year but we know that many GPs do not work full-time, they work part-time, sessionally-----

Dr. Rita Doyle

We do not have the figures on that.

Is it something that could be determined?

Ms Janet O'Farrell

We could provide as-close-as-possible figures. We would have the hours that they generally report working, but we would not be able to tell necessarily if they have GMS contracts. We do not collect that verified employment data, but it might give the Chairman an insight across the register.

Dr. Rita Doyle

It is only those GPs who are on the specialist register in respect of whom we could access that data, As the Chairman probably knows, quite a number of GPs are not on the specialist register.

In respect of the questions on medical manpower we raise in the Dáil, we are often told that there is no problem with medical manpower because there is a greater number of doctors on the medical register than ever before and in respect of general practice, there is a greater number of doctors who hold GMS numbers. But we all know there is a medical manpower shortage. In spite of more people being registered, there still is a medical manpower shortage, how can that be explained?

Dr. Rita Doyle

As already stated, there has been no allowances for the feminisation of the medical profession. In general, women do not tend to work full-time when their children are small. I have an assistant who works five sessions a week with me. She has small children and that is how she manages her life. These are very valuable people and we need to court them.

Dr. Doyle referred to the fact that doctors are not seen as a valuable resource so we will look at the health service and say that beds are a valuable resource, diagnostics are a resource and the infrastructure in our hospitals is a resource. Is Dr. Doyle saying that healthcare professionals, our doctors, are not seen as a valuable resource?

Dr. Rita Doyle

They are certainly not treated as a valuable resource.

I thank Dr. Doyle. We have a second session starting shortly. On behalf of the committee, I thank our guests from the Medical Council of Ireland Mr. Bill Prasifka, Dr. Rita Doyle and Ms Janet O'Farrell for coming before us this morning.

Sitting suspended at 11.24 a.m. and resumed at 11.32 a.m.

In our second session on Irish health sector workforce planning, we are meeting representatives from the Irish Hospital Consultants Association, IHCA. I welcome Dr. Aine Burke, Dr. Laura Durcan, vice president, Dr. Donal O’Hanlon, president, Mr. Martin Varley, secretary general, Dr. Gabrielle Colleran, vice president, and Dr. Conall Kennedy, council member.

I wish to draw the attention of those in attendance 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 this committee. However, if they are directed by the committee to cease giving evidence in relation to 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 or her identifiable. I also wish to advise witnesses that any opening statements they have made to the committee may be published on the committee's website after this meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses, or an official either by name or in such a way as to make him or her identifiable.

Dr. Donal O'Hanlon

I thank the Chairman and members for the opportunity to address them on the association’s concerns regarding the consultant recruitment and retention crisis and the consequences for the delivery of patient care. The IHCA represents 95% of all hospital consultants working in Ireland’s public hospital and mental health services. Our members are calling on us to stand up for the rights of patients, in particular their right to timely access to high quality care. As the committee will have heard from the Irish Medical Council, we are losing hundreds of our highly trained medical doctors and specialist consultants each year to other countries. Doctors want to work in a system that works for patients. Our current system is not working for patients. Our acute public hospitals are understaffed of consultants and patients are waiting far too long for care; many have worse outcomes as a result.

A total of 1 million people are waiting to access care in our public acute hospitals and every day and month new records are broken for the numbers waiting on trolleys, the numbers waiting for an outpatient appointment and the length of time spent waiting. Consultants live with the impact of these deficiencies each day on, for example, children with scoliosis whose life-changing operations have been cancelled three or four times already, the elderly widow, housebound and in pain, waiting three years for a hip operation, and the almost 30,000 women to whom the State promised better healthcare but who are now waiting to see a gynaecologist. Hospitals consultants carry this burden each day, while working on teams with half the required number of consultants compared with the EU average. Many leave. This ongoing exodus is being driven by a loss of hope among doctors. They do not see a future for themselves in the Irish health service and equally have no confidence that there exists the experience, willingness or leadership to fix the Irish public acute hospital system. For the doctors who have left and those who remain, they can see no evidence of concrete improvements over recent years. We all have a responsibility. Committee members, as public representatives, cannot accept this. The people who elected them have put them in a position to fix this. Hospital consultants on the front line believe our system is fixable but we need policymakers to work with us, not against us.

Our population has grown by 9.7% since 2008, with the most significant growth in the number of those aged 65 and over, which has increased by 44% over that period. This is nearly three times the EU average growth rate. It is important to note that, while those aged 65 and over make up approximately 13% of our population, they account for 54% of total hospital inpatient bed days, 37% of day-case bed days, and 26% of emergency department presentations. These demographic changes are one of the main factors driving increased demand for public hospital and mental health services. In the past decade, the number of inpatient and day-case patients treated in our public hospital and mental health services increased by 22%. In addition, unmet demand continued to increase due to significant capacity deficits as is evident from the large numbers on waiting lists and patients being treated on trolleys. The ESRI has projected a further 37% increase in patient demand for hospital care by 2030.

It did not need to be this way. The consultant recruitment and retention crisis has been self inflicted by successive Governments and Ministers for Health since 2012. The unilateral cut imposed on new entrant consultants and the exacerbation of it by not applying the High Court settlement to all 2008 contract holders represented a flawed policy. The realistic solution is to restore parity for all consultants appointed since 2012. The failure to do so has resulted in adverse consequences for patient care and their outcomes. With 500 permanent consultant posts either vacant or filled on a temporary basis, this is resulting in an extremely overstretched work environment and it is impacting adversely on the quality and safety of care that can be provided to patients. The new entrant salary inequity is the root cause of Ireland’s consultant recruitment and retention crisis and the unacceptable numbers of people on record waiting lists which are now the longest in Europe. The failure to address the crisis is destroying the basic fabric of our public hospital and mental health services.

I would like to clarify a couple of key issues on the number of consultants working across our public hospitals. The HSE, before this committee last week, stated that the number of unfilled consultant posts now stands at 377, yet, HSE data confirm that there were 3,281 approved permanent consultant posts in our public hospital and mental health services in June 2019. The same data confirm there were 2,762 consultants in post, leaving about 519 permanent posts unfilled of which a significant proportion are occupied on agency contracts. The number of consultants in post is significantly below required levels.

The association has previously highlighted to the committee that the inability to fill over 500 permanent consultant posts is leading to the appointment of non-specialists to specialist consultant posts. As at February 2019, there were 108 non-specialist doctors in consultant posts, who had been appointed since 2008 when the requirement to be registered on the specialist division to practise independently as a specialist consultant became law. These appointments are also in breach of the terms of the 2008 consultant contract and the HSE’s recruitment rules. Mr. Justice Peter Kelly, President of the High Court, wrote to the Minister, Deputy Harris, and the health service management in May 2018 to outline the resultant serious patient safety concerns this is causing.

The main reasons for the employment of non-specialist division doctors in consultant posts are the new entrant consultant pay inequality and our public health service’s lack of international competitiveness in recruiting consultants. There are significant risk and governance issues with so many non-qualified doctors working as specialists in our public hospitals. They are also concentrated in regional hospitals and mental health services. In January 2019, a total of 44% of consultant posts at the midlands mental health service were occupied by doctors who were not on the Medical Council specialist register, according to a HSE reply to a parliamentary question tabled by Deputy Donnelly. Equivalent figures at other hospitals included 31% at South Tipperary General Hospital, 13% at the Midland Regional Hospital, Tullamore, 12% at University Hospital Kerry, 11% at Sligo University Hospital and 7% at University Hospital Waterford.

Ireland has the lowest number of medical specialists on a population basis in the EU, 42% below the EU average, and between one quarter and one half the number in many specialties. In Scotland, the number of public hospital consultants is 56% higher than in our public hospital and mental health services, when adjusted for population levels. The current number of public hospital consultants in post is far short of recommended levels for most specialties. For example, we need 140 additional radiologists by 2027, or a 55% increase on the current number, to reach the European average when adjusted for population levels. In emergency medicine, the existing cadre of 86 consultants needs to be increased by 90% to provide a safe level of emergency care. The consequences for patients of not having a sufficient number of permanent hospital consultants in post are very damaging and represent a false economy. Almost 570,000 people are waiting to be assessed by a hospital consultant on an outpatient basis. Since the start of the year, more than 53,000 people have joined hospital outpatient waiting lists, while in the past five years, the numbers waiting have increased by more than 205,000.

More than 1 million people are on myriad hospital waiting lists at present. Our public hospital and mental health services can ill afford having approximately one in five of our permanent consultant posts unfilled. It places several important national healthcare programmes at risk. For example, phase 1 of the national children’s hospital, the urgent care centre at Connolly Hospital, could not open 16 hours a day, seven days a week, as was originally planned in July, due to a failure to recruit a sufficient number of paediatric emergency medicine and paediatric radiology consultants. Instead it is open for less than one third of the planned hours. Ongoing consultant shortages put the wider children’s hospital project at risk. The national cancer care programme is failing to meet its requirement of seeing 95% of patients within two weeks, due to a combination of consultant and bed shortages. The national maternity strategy, launched in 2015 following several adverse maternity events, cannot be fully implemented because of a failure to recruit the additional consultants in obstetrics and gynaecology recommended under the strategy.

The national critical care programme has fewer than half the ICU consultants required to provide the standards of specialist care recommended for the most critically ill patients in our hospitals. There are only 35 whole-time equivalent ICU consultant posts, rather than the 82 that are required. The urology model of care, launched in early September, has little chance of success as there are so few consultant urologists. There are 37 urologists in Ireland, which is one third of what New Zealand has, or 15% of the number in Denmark, both countries having similar populations to Ireland. The Government’s national mental health plan, A Vision for Change, published in 2006, is a blueprint for the delivery of a modern service but it remains severely under-resourced. Children and adolescent mental health services have 50% of the specialist staff they need, while older people’s mental health services have a similar deficit. Adult services have 25% fewer staff than required.

There is a cost of doing nothing. The restoration of pay parity for consultants appointed since 2012 will result in an outcome that is better than cost neutral, when account is taken of the resultant patient benefits and the savings on medical agency locums, the National Treatment Purchase Fund, NTPF, outsourcing, and State Claims Agency claims and payments. Medical agency costs have increased by €57 million per annum, totalling more than €90 million per year, compared with 2012, when the then Minister for Health, Senator Reilly, imposed the salary cut on new consultants. Furthermore, the cost of engaging an agency consultant is up to twice that of employing a non-new entrant consultant and three times the new entrant consultant salary. In recent years, the cost of NTPF outsourcing has increased by €75 million per year in an attempt to reduce waiting lists. In addition, State Claims Agency medical compensation payments have quadrupled since 2013, totalling €247 million in 2018, or an increase of €184 million. The cost of restoring full pay parity in one step in January 2020 would have been substantially less than the €45 million per year estimated by HSE and Department of Health. It is questionable in respect of the number of new entrants the HSE has assumed to be on the lower new entrant salary and the lack of allowance for the higher cost of existing agency contract holders. In addition, a high proportion of new entrant consultants are already on the higher, ninth point of the new entrant scale, which would reduce the estimated cost significantly.

The word "crisis", when describing our health services, is unfortunately an overused and devalued term, yet all indicators point to the fact that the delivery of our health services, year after year, faces much greater challenges. In this regard, the IHCA’s #CareCantWait campaign has identified the extent of the difficulties arising from vacant consultant posts. Our acute hospital and mental health services are crumbling with no sign of improvement. One of the most effective ways to address the deterioration would be for the Government to restore pay parity for consultants appointed since October 2012 to end the medical brain drain and ensure that Ireland will become a more attractive place to pursue a medical career.

I thank the committee for inviting the association to its meeting. We look forward to a discussion with members on the issues and challenges I outlined .

I thank our guests for their attendance. More than 1 million people in Ireland are waiting for care. Nothing like it has ever been seen here and nothing like it exists anywhere else in the developed world. More than 100,000 men, women and children have been waiting more for than a year and a half just to see a consultant. Children have been waiting for years for surgery, including some with scoliosis, as Dr. O'Hanlon noted, whose spines are curving to almost 90°, something that does not happen in any other European country. Elderly men and women must wait for days on trolleys in accident and emergency, while there are unsafe staffing levels in various specialties, as mentioned in our guests' opening statements. There are hundreds of unfilled posts and we have the lowest level of consultants and the longest waiting lists anywhere in Europe. There are non-specialists in specialist roles and doctors are leaving medicine in record numbers. Agency costs have shot up more by more than €60 million in recent years and national care programmes, including for cancer and maternity care, are at risk. The national children's hospital's satellite could not even fill its posts and as a result operates on less than it was meant to. Pay inequality for new entrants has been identified and accepted across parties, by the Opposition and the Government, and has been championed and pushed by the medical community for a long time.

Given all of these crises in healthcare that leave men, women and children waiting, suffering, deteriorating and dying, and given the relatively low cost of fixing this bloody thing, why is the Government steadfastly refusing to do so or even to meet representatives of the consultants to talk about it?

Dr. Laura Durcan

We are here because we want to help. The only reason we come to any of these things is because we want to help and we really believe in the public system. I could say the same for everybody who is on the Joint Committee on Health. The only reason we show up in the morning is that we believe people should have timely access to excellent care and that it should not matter where someone lives, how much money he or she earns, or what is in his or her local hospital. All of those things should be irrelevant. Every person should have equal access to excellent care. Once people get into the public health system, we do an excellent job. They are really happy. When we survey our patients, we find that the ones we have seen are really happy. As has been said, it is the million people we have not yet seen who are disgruntled and they are totally entitled to be. They have not accessed care.

The Government has a fear of dealing with us and with doctors in general. It has this horrible fixed narrative that health is a big black hole or an unfixable problem where good money goes to die. The Government feels that it continues to pour resources into this big black hole and nothing comes from it. In a way, the Government chooses not to engage with us because it does not want to face up to that black hole or start looking at how to pull back from it.

I look at examples of solutions. This morning I was in a clinic and I met one of the nurses. She told me to make sure to tell the committee that the staff are doing a great job. I said that I would. The truth is that the people who work in our health service do a great job. We have fabulous healthcare workers, but we do not have enough of them.

I can give my own hospital as an example. I work in Beaumont Hospital. We used to be terrible, but our numbers are now excellent. The rheumatology department in Beaumont Hospital went from having two rheumatologists to having three. Our waiting list went from three and a half years to less than six months. I delved into the data for the other specialties in our hospital. There were thousands of people waiting for longer than 18 months to see an orthopaedic surgeon. The hospital added 1.5 new posts and changed the triage system. Everyone now on that waiting list has been there for less than nine months. That is pretty much the only orthopaedics department in the country that has achieved that. Now, nine months is still terrible, but it is not the same as waiting to be seen for a year and a half. The same can be said for respiratory care. Nobody has been waiting for longer than six months because a new body was introduced and took the tail of the waiting list. The waiting list is now gone.

The only places in our hospital that have not seen improvements are the places where people have resigned and left. We have lost three or four people in the dermatology department to the private sector. That waiting list has skyrocketed. That is the only place where we have had to put some of the workload out to tender via the National Treatment Purchase Fund, NTPF. Yesterday, we were discussing the cost of getting people out for their dermatology assessments, their biopsies and their subsequent treatment. I will not outline the numbers because I would be killed, but they were massive. I was absolutely astonished. That is the only place in our medical service where we are outsourcing. That was a huge cost. It certainly cost more than it would cost to hire three consultants a year.

I would like to come back to the lack of movement. I have had the health brief for about a year and a half and some things were soon very obvious to me. They will be very obvious members of this committee who have been doing this for longer than I have. One of these things was the fact that the financial emergency measures in the public interest, FEMPI, legislation applying to GPs needs to be reversed. Many people have pushed for that and it is beginning to be reversed. Another was a stance taken by the nurses and midwives. Things needed to be done there and movement was achieved. They did not get everything they wanted but there has been movement and provisioning in the budgets for that. Another thing that obviously must happen immediately is that new entrant pay inequality must be eliminated for consultants. We are running out of doctors. To the best of my knowledge there has been no movement on that. Is movement happening behind the scenes, out of all of our sight, or are consultants hitting a brick wall with the Government?

Dr. Donal O'Hanlon

The Government has been avoiding engaging on the topic and we are not having any behind-the-scenes meetings with it.

Can I ask why? Dr. O'Hanlon may not be able to answer. The figure we received from the Department of Public Expenditure and Reform is €45 million. That does not take into account reduction in locum costs or real cash savings, so let us assume the figure is closer to €20 million over a full year. We do not know exactly. A full-year sum of €20 million is minuscule in the context of the €17.4 billion current spend unveiled yesterday. This is an obvious way to save money. Arguably it is a higher priority than some of the items we saw in the budget yesterday. Do the witnesses have a sense of why we are seeing such intransigence on the part of the Government towards one of many obvious solutions to the need to hire more doctors?

I will call on Dr. Colleran and then Mr. Varley.

Dr. Gabrielle Colleran

I think it is ideological. That is only my opinion and my reading of the situation. It is partly because our public health system has been politicised and weaponised. When I was a trainee, consultant posts were really sought after. They were really competitive. There were multiple applicants and the best person would be picked. In 2012, the then Minister, Senator James Reilly, imposed a unilateral 30% additional cut on new entrants' pay. He was warned that it would decimate recruitment and retention. He did it anyway. Multiple Ministers since, including the current Taoiseach, said that this was a mistake, it had not worked, it was not saving us money, and it needed to be reversed. However, nobody has had the political courage equal to desire to say the Government made a mistake. As doctors, we live with the fact that there is uncertainty in medicine. We make our best decisions with the information we have. I am a radiologist. We have an error rate of between 3% and 5%. We know we make mistakes. We have to learn from them, improve and move on. To me it seems there is an ideological or political determination not to admit that this was a mistake. This measure never saved us money. We are spending a fortune on agency locums, far in excess of what we would spend on permanent staff who would be leading, innovating and developing the service for our patients. Everybody seems to see the figures, recognise the impact on patients and realise that this needs to be changed, but there is a lack of political courage to do it.

The Taoiseach made a commitment in the Dáil on 24 October 2018. He said he would sit down with the Irish Hospital Consultants Association, IHCA, which represents more than 95% of consultants, and our colleagues in the Irish Medical Organisation, IMO, and simply do this. So far what we have seen is kicking the can down the road - inaction, lots of talk, selfies and spin. I call on all the members present to say "Enough". We are not a political football. We are the people who look after the patients of this country - the constituents, families, friends and children of the members of this committee. We do not have enough people on our team to provide timely access to high-quality care. Every person in this country should expect that if his or her GP feels he or she needs access to secondary or tertiary care, he or she will get it within six weeks. That is their right. Our Constitution says that the Government has a duty to defend their right to life. The 1 million people waiting on lists, some of whom have been waiting three or four years for access, do not feel very defended or protected by politicians right now.

The five of us who are here this morning should not have to come here like this. We should not have to call politicians out on an issue as basic as having enough people to staff our teams safely. Our number of consultants per capita is half the OECD average, and some of those comparator countries are not rock stars with whom we would want to be compared. Some 20% of our posts are empty. We have the fewest consultants per capita in Europe. Our system is burning out and spitting out our doctors because those of us who are in post are firefighting to protect patients from the gaps in care. We are on intolerable call rosters, we have workloads that are not safe, and we go to work and do this every day to protect patients. We look to politicians to lead us and to give us the resources and the front-line staff to provide the high-quality care that we provide to everybody when they need it, but politicians are ignoring us. They promise to engage with us and then do not follow through. We are willing to meet them any time, day or night, Monday to Sunday. We work those hours 24-7, 365 days a year. We provide the medical cover. There has been enough talk. We have implementation deficit disorder in this country. It is time for politicians actually to do something.

I thank Dr. Colleran. My real concern is that yesterday-----

Mr. Varley wished to comment.

Mr. Martin Varley

Deputy Donnelly has asked a very important question. It has been going around my mind for the past seven years. When will people really engage at ministerial level and at official level? I ask this question after representing the food sector and the health sector since 1990. I am not a novice in representation. Prior to that, I worked for two years in the Department of Finance. I have an understanding of what officials are there to do. That is the nub of the problem.

We have an inexplicable position where the Minister of the day is not engaging on an issue and the senior officials in the relevant Department, or potentially Departments, are not engaging either. My understanding, prior to moving to the private sector, was a civil servant had a responsibility to analyse problems and formulate the best solutions. We have made most of the analysis ourselves and I have not seen any from the other side. It is a win-win solution and would be better than cost-neutral, as we have alluded to, if we allow for the better outcomes for patients, leading to shorter stays in hospitals, fewer medical bills and less home or nursing homecare. If we leave patients on lengthy waiting lists, as we are, it becomes a big problem for the effectiveness of delivery of care across the spectrum. There would be a large cost saving.

I again request what we have repeatedly asked of the Minister. I ask him to engage and sit down with us. The question is why he is not sitting down with us. Any public servant with a role to deliver more effective and efficient service in the State should sit down with the organisation that is coming to the table with solutions and pointing out the direction of travel. If that public servant is not sitting down with that organisation, it indicates a problem somewhere on the other side.

It is what I am trying to understand. Fianna Fáil's position is unambiguous. In government we would reverse this in full and immediately. We included it as one of the top priorities for the budget negotiations and although we saw movement on some matters, for the second year in the row we got no movement on this issue. I do not understand it and it makes no sense. It is not logical. When I saw the budget documents yesterday, it really bothered me that there was no provision made for this. The delegate will understand as someone who worked in the Department of Finance that there is a loose suggestion that all parties will come together for talks with the Government at some undetermined date in the future, but there is no provision made in the budget for next year for bringing about the reversal if the talks are successful. We heard from the Medical Council earlier that for every one doctor leaving medicine in 2014, three doctors left in 2018. It feels like we have passed a tipping point in the collapse of access.

Perhaps I might get the thoughts of the delegates on a final point. The shortfall in the number of doctors is far more than what we typically speak about. Dr. O'Hanlon indicated the shortfall was approximately 500 consultants; there are approximately 3,300 approved posts and we are missing approximately 500 full-time consultants in thse posts. That is a number that would keep us from having the lowest level of consultants in Europe. Accepting that the figure is 43% below average, based on the latest data, getting to the European average number of consultants for our size of population would require us to add approximately 1,600 posts. If we are just to get to the European average, therefore, we need to fill the 500 posts and hire an additional 1,600 consultants. That suggests we are short more than 2,000 consultants. Does the Irish Hospital Consultants Association have a view on what it would take just to get to a normal level of doctors in this country?

Dr. Donal O'Hanlon

Comparing the numbers internationally, we are very poorly served by our number of consultants. We could compare the number to that in Scotland which has 60% more consultants. As it also has more beds, those consultants can work more efficiently. Going back to the Deputy's earlier question, there is a feeling of inertia and helplessness in that the Government is not really making any change in the health service, as far as I can see. There is much talk about what might happen ten years from now, but this is something that could be tackled relatively quickly and it would stabilise the system.

I thank all of our guests for coming and the work they do. I am not just referring to their day jobs which would probably be enough for most people, as they do additional advocacy work. As a former shop steward, or whatever term one may use, I know that work is done in one's own time and at the expense of time spent with families, etc, but it is appreciated.

I have a few questions, but I will begin by referring briefly to the National Treatment Purchase Fund, NTPF. I had the pleasure of attending the IHCA annual delegate conference at which I spoke to one of the delegates' colleagues. He advised me of the mechanism being used with the NTPF and the targeting of those who had been waiting the longest for their first appointment. Such persons are being wiped off the list after seeing a private consultant, but they are then placed on another list. They are not getting any closer to getting better, rather they are being shifted from a list that looks atrocious to one that looks slightly better. They will soon be joined by others. Will the delegates explain how the process works and the real impact of the NTPF which is sometimes sold as a mechanism to solve the problem of waiting lists?

I do not have and have never had private health insurance. People in my immediate family do not have it and most people in my extended family do not have it. There was mention of 1 million people without insurance and they are not anonymous to me. They are not just people I see in my advice clinics either. They are my close family members and this is not something I must read about in the newspapers. I live this experience. Will the delegates explain the impact of the NTPF?

Dr. Gabrielle Colleran

The purpose of the NTPF is to be a short-term sticking plaster solution, while we add capacity in the public sector. Essentially, money is being transferred from the public health system to the private system. When there is such low staffing and restricted access, there is major risk to patients who have to wait. We are forced into a position where we must try to buy access to quality care wherever it is possible to do so. Deputy O'Reilly's point is absolutely correct as if people are seen and have their first outpatient appointment, they might need a scan and be transferred to another list. They would be new to that list. The numbers might improve, but we must see the impact on the patient. What would work for patients is having enough consultants in posts to provide access to care in order that everybody can be seen within six weeks. It is something we could achieve if we all worked together with a shared vision and a focus on patients by listening to them and responding to their needs. That is what the Peoples Needs Defining Change platform in the HSE is all about. It is about reacting to the changing and ageing population, where one person in eight is over 65 years to where one in six will be over 65 by 2030. The NTPF is just a short-term sticking plaster. We need capacity in public hospitals. Dr. O'Hanlon mentioned Scotland. It has twice the number of consultants and 30% more beds. We need investment to provide capacity in the public sector because the NTPF is very expensive. Investing in the health service is not just about increasing the budget but spending the money properly on front-line staff and in providing capacity to facilitate the treatment of patients. The quote from Warren Bennis is that we are "over-managed and under-led". Therefore, we need the leadership to show the vision of investing in the public health system in order that we will be staffed at capacity to meet the changing population's needs.

Dr. Aine Burke

We can link the consultant recruitment difficulties with the NTPF lists. We have widely acknowledged that there is a national difficulty in recruiting doctors and consultants, particularly in regional hospitals. I am based in the west and north west where there are examples of recruitment difficulties. For example, in Letterkenny four acute medicine posts have been brought to advertisement recently and there has been a failure to fill three of them. One third of the hospital's necessary radiologist posts are filled, while half of the emergency department posts are filled on a permanent basis. There is a difficulty in filling posts in Mayo University Hospital and Sligo where posts must be advertised two, three or more times. Some of them remain unfilled. The effect is that in County Mayo there are over 8,000 people waiting for an outpatient appointment, according to the NTPF waiting lists. In County Sligo there are almost 17,000 people on the lists, while in Letterkenny there are just under 18,000 on the lists. Between the three hospitals which have clear difficulties in recruiting consultants, there are 22,800 people waiting for over six months to be seen at an outpatient clinic. We can directly correlate the recruitment difficulties with the long NTPF waiting lists.

Dr. Conall Dennedy

We base many of our statistics on what we see on the NTPF waiting lists. I would like to point to an inaccuracy I have seen in the figures quoted by the NTPF for the waiting list for endocrinology in Galway, where I work as an endocrinologist. According to the NTPF figures, there are 144 patients waiting for an outpatient appointment at our centre for diabetes and endocrinology. The longest waiting time quoted on the site is up to 12 months. As I said, I work in Galway University Hospital. As I triage the general endocrinology waiting list, I am familiar with the real figures. There are 1,543 patients waiting for an outpatient appointment to see an endocrinologist in Galway. Some 890 patients have been waiting for more than six months to see an endocrinologist in Galway, of whom 50 have been waiting for more than three years. Based on the endocrinology waiting list in Galway University Hospital alone, the official figures on the NTPF's website represent a tenfold underestimate of the actual numbers of patients who are waiting. I can see from the figures in front of me that the longest waiting time has been underestimated by approximately two years and four months. I will explain what this means in a patient context. I suspect that this also applies to paediatrics. I have seen a significantly higher number of paediatric endocrinology referrals to the adult endocrinology clinic in Galway. By the time a child over the age of 13 years has waited the three to four years required to see a specialist paediatric endocrinologist, he or she will be classified as an adult. This denies children access to endocrine healthcare at a vital stage in their development - I emphasise that endocrinology is vital to the development of children - and to the transitional care model which represents best international care.

The figures that cited by Dr. Dennedy are shocking. My views and those of my party on the NTPF are well known. It is not going to be news to the delegates that we do not think investment in the private sector will improve the public sector. Such investment has never helped the public sector and will never do so.

I would like to ask about what is being done. Representatives of the Medical Council have told the committee about the culture in which medicine is practised. When they were questioned, it became obvious that an understaffed medical facility was a tense and fraught atmosphere in which to work. The delegates from the Medical Council described the culture in which medicine was practised as almost toxic. It is not that the individuals working in the sector are toxic but that the organisation is dysfunctional. It is no reflection on the people working in it; it is more of a reflection on the system. It has been suggested some doctors and consultants who are abroad might be available to come home. I know that some of the delegates have returned from overseas and their return is most welcome. Is anything specific being done in that regard? When we speak to individual hospital managers, we learn that they use informal networks for these purposes. One such manager has told me that people with whom she was in school now have sons and daughters who are working overseas as doctors and consultants. She is working hard to try to get them to come home. Are the delegates aware of any specific measure being taken to make it attractive for consultants who are abroad to come home? Are packages being offered? Is every effort being made to attract doctors back to Ireland? Is it simply the case, as I suspect it is, that the word is out that the Irish health service is a deeply unattractive place in which to work and that Irish doctors overseas are deterred from returning home on that basis?

Dr. Gabrielle Colleran

Many of us have come back from abroad. Dr. Durcan likes to say Irish people are like salmon in the sense that they want to come home. Irish people are very passionate about their healthcare system and really want to contribute to it. The reality is that when one goes away to work in different systems that are properly staffed and have the capacity needed, it is very hard to come back to work in a system that does not work for patients. I will explain what I mean by referring to the concept of moral injury which comes from the military. It means that doctors tend to move into healthcare because they care about people, want to help patients and improve things. When an endocrinologist like Dr. Dennedy is working in our system, he deals with patients who have to wait 12 or 18 months to access the CT or other scans that determine the next forms of treatment they need. In such circumstances, the greatest impact is on the patient. It is hugely damaging for them and their lived experience. For the doctor who wants to help and improve things, there is a moral injury that occurs day in, day out when he or she is working in such conditions.

We have heard about the culture in the medical sector and the bullying that happens. There is a very high level of burnout among doctors in our system. When people start to burn out, the first thing that starts to happen is dehumanisation. Doctors start to lose their empathy for others because they are so overstretched. Our consultants have huge workloads. Staffing levels are at half of the European average. Consultants have to run around to cover the gaps. They try to protect patients from risk. They try to pick out the person among all of those who have been on the waiting list for 18 months who has a hidden cancer or a degenerative neurological condition that needs earlier intervention. They have to manage significant levels of risk. There are substantial levels of burnout and moral injury as a result of being unable to provide care.

Any time I treated a child in Boston who needed an MRI scan, I was able to ask his or her parents whether an appointment that evening or on the following Saturday would be best for them from a employment point of view. I was able to ask parents what worked best for them. As a doctor, there is great satisfaction in being able to provide care when people need it in a way that is responsive to their needs. Doctors in our system do not experience this because of the lack of capacity. No amount of resilience training or packages will help. We need to staff our teams. I appreciate that pay parity, pay equality and equal pay for equal work are some of the basic things in which Deputy O'Reilly's party believes. For us, it is a basic part of safe staffing and making the workplace attractive. Proportionately, we train the highest number of doctors in Europe. Our doctors are of a really high quality and can go anywhere. They are loved in the New Zealand and Australian medical systems.

They are very mobile.

Dr. Gabrielle Colleran

If one visits every high level academic institution in the United States, the chances are that one will find more Irish people in them. Our teams in emergency departments are firefighting on the front line. We have 89 emergency department consultants across 29 acute emergency departments. There are 42 such consultants in one part of Australia alone. We have exported our medical talent and need to bring them back now. We need to change the narrative. To be honest, the Government has been at war with consultants for ten years. It has to stop. We are the Government's full-forward line. Consultants are part of a health team that includes the Minister, the Department of Health and the HSE. We have to work with patients as part of a team to deliver care. As I said, the narrative has to change. Health has to stop being a political football that is used for political gain by people on either side of the political divide. We have to start putting patients in the centre where they are. None of us has a job without the public and patients. We would all do well to remember that.

Dr. Donal O'Hanlon

I will address the question of focusing on recruitment initiatives, rather than word-of-mouth recruitment, of which, traditionally, we do a lot. It still goes on. When we start to talk about pay parity and working conditions, it tends to be a very short conversation. I am not aware of any initiative in the past few years that sought to recruit Irish doctors working abroad. The nursing initiative was not that successful, but at least it was an attempt to bring people back. The final point I would like to make about recruitment is that fewer jobs are being advertised, partly because there is a fear that applicants will not come forward.

I am trying to put my final question delicately because I do not want anyone to panic. Is the IHCA aware of an elevated level of mental ill health among consultants due to the shortages? I am not aware of any specific effort being made by the Government to provide for pay parity. Without putting words in anyone's mouth, I do not think the delegates are aware of any such initiative either. Nothing in the outcome of the budgetary negotiations, as announced yesterday in the Minister's Budget Statement, suggests pay parity is on the agenda. For the avoidance of doubt, are there meetings scheduled between the IHCA and the Minister for Health?

Dr. Donal O'Hanlon

No.

There is collective disappointment with what emerged from the budget negotiations. At the very least, I believed there might be some mention of pay parity, even if nothing concrete was announced. There was nothing in it.

Dr. Donal O'Hanlon

There are no scheduled meetings with the Government. No engagement is scheduled. We would not necessarily know if people were developing mental health problems. As we get older, the stresses and strains of working in this system lead to a great deal of difficulty with the retention of consultants, as well as recruitment.

Dr. Donal O'Hanlon

The chances of people working beyond 61 or 62 years are dropping by the year.

Mr. Martin Varley

I would like to comment further on the two interlinked questions asked by the Deputy. She asked if efforts were being made to recruit highly trained specialists to come back to take up posts in Ireland. An excellent Irish specialist trainee who spoke at our conference, Dr. Toby Gilbert, is now a consultant at the Royal Adelaide Hospital.

He presented his views on that, and did so quite well. He has a stay or go decision to make in his life vis-à-vis his career. The stay means staying in Australia and the go means going home and being with his family and friends and back in the Irish health service. His conclusion was that for as long as there is pay inequality, he has no decision to make. It is already made for him. That is the problem. The difficulty we have is that for as long as successive Ministers for Health perpetuate the inequality that was introduced in 2012, it will continue to drive away our highly trained specialists who are embraced in other services and given all the resources they need to treat patients on time.

One third of the graduate classes, the intern classes, goes to Australia each year from all the colleges and locations. More than 200 interns are in the Perth hospitals. They go from there to other hospitals and they stay. They are very well looked after. It is not about being looked after but being valued. They are valued to the extent that there is no discrimination. They are also given the resources to treat patients on time. They are the two basic ingredients to get people back.

I will ask Deputy Kelly for his comments.

Is it comments or questions or both? The Chairman knows me too well. I have a few questions and I do not wish to go over old ground. I have great sympathy with regard to the pay differential. None of us can give a guarantee of being in the Oireachtas or in government after the next election, but the issue will certainly have to be dealt with by any coalition that is in place. It is high time it was dealt with because it is a significant contributing factor. Given my age profile, I know many of the people who are affected by it. I have a practical question. Is the IHCA affiliated to the Irish Congress of Trade Unions, ICTU?

Mr. Martin Varley

No. We are an association, not a union.

Why is it not a union?

Mr. Martin Varley

It is not a union because the association was set up on certain principles. It is an association to do two things in particular: first, to work on delivering improved healthcare in Ireland and to contribute to that in any way we can, and second, to represent issues and concerns of members in trying to do that.

May I make a suggestion? The association should become a union.

Mr. Martin Varley

That is always a possibility.

It is just an observation.

Mr. Martin Varley

I appreciate the comment. As a former civil servant who used to work in the equivalent of the Department of Health, I do not believe it is a deciding factor as to whether one engages with an association representing 95% of a particular workforce. It was cited in the committee last week as one of the main reasons. I call that inappropriate. It is not a requirement and should not be a requirement.

I am not-----

Mr. Martin Varley

I will finish the second point, which is strongly related.

I did not ask Mr. Varley a question, but he can proceed.

Mr. Martin Varley

Second, it was also cited that engagement is happening with another group, a union, because it is a party to the public service stability agreement. The association is also a party to the same agreement.

I understand that.

Mr. Martin Varley

We were requested to do so by the Department of Health in late 2017 and wrote back to confirm fully that we would collaborate. Not only that, we stressed that the association has a long history of not taking industrial action.

It is an observation, and I believe it would help the association. I strongly suggest it do that, for many reasons that we do not have time to discuss here. I believe it is a weakness that it does not do it. It is a weakness on many levels.

I wish to refer to different areas because I agree with many of the comments earlier, so I do not wish to waste my time by dealing with the same issues. Does the association agree with the recommendations of the de Buitléir report? I am not talking about how we are going to do it as that will require a significant amount of funding, effort and turnaround time. Does the association agree with its findings?

Mr. Martin Varley

I will make two comments on the report. First, it identified two stand-out problems vis-à-vis delivering timely care to patients. The first is capacity in terms of beds, diagnostics and so forth. The second is the need to recruit more consultants and front-line staff. Our major concern-----

Does the association agree with taking private practice out of public hospitals?

Mr. Martin Varley

Our major concern with regard to discontinuing to take income from privately insured patients through their health insurers is that it will create a loss of approximately €7 billion per decade at a time when we need substantial investment in capacity in beds, diagnostics and equipment that is crumbling. We are very concerned that the funding will not be put in place to provide the replacement equipment that is long overdue, the 2,600 additional beds that are in the national development plan, which will cost €2.6 billion, and the staff for those beds. If we were convinced that the funding would be provided, we would examine how to do all the things that are recommended in Sláintecare and engage very positively in that regard. We have a genuine concern that the funding will not be provided and we do not have the luxury of rejecting €7 billion in a decade that we otherwise need.

Can Mr. Varley answer the question? I am on the clock so perhaps the witnesses could keep their replies concise, as I have a number of questions. In principle, does Mr. Varley agree with taking private practice out of public hospitals?

Mr. Martin Varley

The difficulty we have in this regard is, first, we were never invited to the Sláintecare committee to discuss it.

It was a cross-party committee.

Mr. Martin Varley

Second, we requested an invitation to the committee three times.

I was not aware of that.

Mr. Martin Varley

We have been seeking meetings with the Minister for the past seven months.

Will Mr. Varley answer the question?

Mr. Martin Varley

I will answer the question. We would like to meet the Minister and the relevant teams to discuss what is being proposed because it is not entirely clear to us. The de Buitléir report identified many problems and he suggested that we should remove private care from public hospitals.

It is not going to happen overnight, but over a period of time. The association either agrees with it or it does not. Mr. Varley should let me know. It is the fourth time I have asked the same question.

Mr. Martin Varley

There are very significant issues that must be addressed-----

I accept that.

Mr. Martin Varley

-----and agreement with it depends on whether it addresses the issues. Resourcing the hospitals-----

I am asking about it in principle. The resources will be provided over a significant period of time. This will have to be a graduated process. The ship will have to be turned around and put back out to sea over a period of time. Would Mr. Varley agree with it?

Mr. Martin Varley

Exactly. This is the point. If one puts the capacity in place, the question becomes irrelevant-----

Mr. Varley does.

Mr. Martin Varley

-----because a large number of people who currently have health insurance in Ireland would no longer require it. They would not be required to go to a public hospital using health insurance.

I am taking it that Mr. Varley agrees. He can contradict me if I am wrong.

Can we bring in Dr. Durcan?

Dr. Laura Durcan

I appreciate that the Deputy is on the clock, but I did a clinic at 7 this morning so I could come to speak to the committee, so it works both ways.

Excuse me, I do not take comments like that. I did a 17-hour day yesterday as well, so Dr. Durcan need not think she is unique.

Dr. Laura Durcan

Okay. The issue for me is that I deal with acute patients who present at the emergency department. I have no understanding of whether they have private healthcare or what type of funding they are bringing with them to the emergency department. These are people with strokes and heart attacks. They are too sick to use the private system. What we are here today to discuss is creating access for everybody to the public system. Martin Varley is saying that whether one decides to have private health insurance should be an irrelevance. If somebody decides to have private health insurance and have his or her tonsils dealt with in Blackrock, that is the person's own business. The truth is that any of us could be in a car crash on the way home, and if we suffer trauma, we go to the public hospital. If we have a stroke, we go to the public hospital. This discussion is about the public hospital. If the public hospital had enough consultants and beds, how people are funding their healthcare would become a complete irrelevance. It would be just that they go to the hospital. That is why we are here today.

I do not have a private practice and have no vested interest in private patients. I am here because I want to make things better. We want to make things better and for VHI, Laya Healthcare or the like to be a choice. Whether that lines up with Sláintecare or with the de Buitléir report will be borne out over time with a great deal of discussion. What we want is for everybody to be able to access timely care in an emergency department and be seen by excellent people. That has yet to be borne out.

I will put Deputy Kelly's question in a different way. Does Dr. Durcan believe that people with private health insurance should get preferential treatment in our public system?

Dr. Laura Durcan

No, absolutely not.

Dr. Gabrielle Colleran

Can I come in on that?

Thank you, Chairman. You have been very helpful.

Dr. Gabrielle Colleran

The Deputy's question was whether we believe ideologically in a public system that has equal access at the point of care.

It was a bit more complex than that but Dr. Colleran can answer her version of the question.

Dr. Gabrielle Colleran

What Mr. Varley was articulating and what Dr. Durcan referred to were our concerns with the funding model. Our acute hospitals get €4.5 billion in funding, so €700 million of funding from private health insurance being taken out is a huge loss of funding. I work in paediatrics and very few children have private health insurance. I do not know when they are coming to me if they have private heath insurance. My concern, when I look at our recruitment issue, is that our recruitment issues are most prevalent in the specialties where there is the least private practice and the most type A contracts, such as emergency, psychiatry and my specialty, which is paediatric radiology. I am concerned that if the private income were to be removed, our recruitment and retention crisis would get worse. I work with equipment in both of the hospitals I work with that is beyond its end of life and has not been replaced. There is a huge need for investment in the capacity, the people and the infrastructure. I worry that €700 million a year being taken out of our €4.5 billion a year funding will have a catastrophic impact if it is not replaced. I am being very honest with the Deputy on that.

Can I continue because I will not have any time to ask more questions otherwise?

Dr. Gabrielle Colleran

We did try type A contracts back in 2010 and they did not work.

Fair enough. I am with Dr. Colleran when it comes to the two-tier system. It cannot operate anymore and the drawbacks are huge. The finances of it do not make sense. It is obvious it cannot continue.

On changes to contracts, we also need to have greater transparency with the public-private mix because that would help everyone. It would help the Irish Hospital Consultants Association, it would help us as decision makers and it would help in the provision of funding. We will have to have it to deal with that turnaround period of time in the next decade or so to achieve what we want to achieve with Sláintecare. That is my last comment on that matter.

I come from the mid-west. I am on a campaign at the moment regarding University Hospital Limerick, UHL. The Chairman is my colleague in this campaign. Neither of us is even from Limerick. We are from Tipperary and Clare, but it is our main hospital. It is a scandal if one does a comparative analysis on the volume of doctors and consultants in UHL versus Beaumont Hospital. They are both model 4 hospitals. I have the tables done on this analysis and it is a disgrace. It cannot continue. The people of the mid-west are being discriminated against. UHL had eight medical physicians and consultants who left in recent years. A number of them joined different organisations. Two of them moved because they had more than 100 patients on their lists and they just could not cope.

I have only one more question after this but I asked the Medical Council of Ireland about this earlier and it did not have very good quantitative analysis, to be fair to it. It will improve that based on suggestions we made. I return to the issue of why consultants are leaving. There are a variety of reasons for this, and I dare say they are not always financial, although some of them are. Working conditions and geography are other variables. Are there any instances of consultants leaving that are specifically geography related based on the structures of the HSE in certain locations or does the Irish Hospital Consultants Association have any evidence of same?

Dr. Laura Durcan

I totally agree with the Deputy about the UHL staffing issues. I demonstrated earlier that our waiting lists at Beaumont Hospital have plummeted as our consultant staffing levels have come up. The outpatient lists in UHL and the wait times are as a direct result of consultant understaffing. The Deputy is completely right about that.

The geographics of the country have always been a factor. We spoke to-----

Sorry for interrupting. Also in the mid-west, we do not have a private hospital. We have Barringtons Hospital, but the witnesses know what I mean. We do not have a full overnight private hospital. I am trying to correlate the figures based on the structures. Our region is the only one that got reconfiguration. We were reconfigured before the solutions to capital funding were ever provided. We are an outlier in that regard. I am trying to see if there are correlations with those leaving because of that.

Dr. Laura Durcan

From speaking to colleagues who work in UHL, the medical call in UHL is extremely challenging in particular. As the Deputy says, there are people who will have 100 patients on their bed on a Monday morning at their ward round having done a whole weekend, and that sounds horrendous.

On the geographical challenges in Ireland, if we look to the past, there have always been people who have wanted to staff the regional hospitals. The fall in staffing in the regional hospitals has been very recent. It is really only since 2012 that we have seen that there are no applicants for those jobs. There were gastroenterology jobs in University Hospital Waterford that had ten or 12 applicants in the past. If a gastroenterologist job in University Hospital Waterford were to be advertised now, it would be a good result if one suitable applicant came forward to fill it. The same can be said for all the other hospitals. There have always been people who have wanted to be county physicians and there have always been people who have wanted to be down the country for many different reasons. Historically, there have not been specific geography challenges, but now there are hospital challenges whereby people are slow to come home for a different salary and, equally, they are slow to come home to a hospital that is almost entirely staffed by locums. They do not want to work there.

Hospitals such as UHL. I was very much taken by what the Irish Hospital Consultants Association said recently about having no confidence in the Minister for Health, Deputy Harris, and I have been very much taken by what the witnesses have said here today. I want to quote what the Irish Hospital Consultants Association said on escalating a campaign, and I would like it to give us more information on what that campaign is. That is the first question.

The second question is as follows. The Irish Hospital Consultants Association said the Minister did not have "the authority, understanding, inclination or experience to deliver timely, quality hospital care ... or improving conditions for patients". Very few people have been as critical of the Minister on various different issues as I have. Others have as well, to be fair to them. I am saying this as an Opposition spokesperson, but the tone of that statement did not help the Irish Hospital Consultants Association. I have to be brutally honest about this. It did not help. I listened carefully to what the witnesses said earlier about being on the one team, stopping this being a political football, and that the different sides of the political divide do not matter. There are many sides to the political divide here, not just two. The witnesses may want to really remember that because I am not sure it comes across a lot of the time. There is huge sympathy across politics with the issues the Irish Hospital Consultants Association are dealing with and the consequences for patients. Again, I am saying all of this as an Opposition spokesperson and I have put out statements that are critical of the Minister on numerous issues, but to refer to the Minister's inclination, understanding and experience, particularly to refer to his experience, needs an explanation. Also, when the Irish Hospital Consultants Association said it was escalating its campaign, what did that mean and how will it manifest itself?

Dr. Donal O'Hanlon

I will start by attempting to respond about the wording of the statement. That was a response to a feeling of anger and frustration throughout the membership of the association throughout the country. We have seen matters deteriorate over the years and we have also felt we were not being invited in to be part of the solution. We can see the waiting lists increase by 37%-----

I agree with that by the way.

Dr. Donal O'Hanlon

-----and we have seen trolley counts increase. Our members are trying to deal with this daily throughout the country and we do not feel there is any urgency to address that. We also feel that there does not seem to be any wish to work as a team to try to fashion an answer to that problem.

The word "experience" was the one that got me, to be honest. I can ask about the campaign.

Mr. Martin Varley

We sought meetings with the Minister on numerous occasions. Our last meeting was in early March. He agreed to meet us and to speak at our conference in mid-September. He wrote with his apologies that he could not attend that meeting and committed to meet us in the following week or so. Despite numerous calls to his private secretary, I got no response to engage. That has been the pattern and not just in recent months. When one is trying to come to the table with solutions and to engage, it becomes quite frustrating and difficult for people who are trying to deliver care in difficult circumstances on the front line.

There was a question of what we are doing with our Care Can't Wait campaign, which I will get to. A number of months ago, when we met the Minister, we determined that an avalanche of problems were brought to our attention that we had to highlight relating to the difficulties in delivering timely, quality care to patients. We touched on some of them today. For example, in University Hospital Limerick, six whole-time pathology post are approved. There has been failure to fill one third of those posts over the last seven years, having been advertised repeatedly, and it is causing major problems in timely diagnostics. It is also jeopardising the post mortem service, which people like to see delivered in a short time for all the obvious reasons. That is now hanging by a thread and has been for the last number of months.

I watched the committee's earlier engagement with the Medical Council and the Deputy asked a pertinent question for which I do not think it had an answer. He asked if the shortage of consultants and the overstretched nature of work in hospitals is giving rise to increased claims. I checked the situation vis-à-vis the State Claims Agency and clinical claims. In 2010, there were 1,935 active claims. Last year, which is the most recent year we have statistics for, there were 3,196, a 65% increase in less than a decade. That is indicative of what we think is happening and we know why it is happening. Patients rightly have an expectation to get timely, quality care. When 1 million people are on a waiting list, that does not happen. People arrive and their treatment is effective insofar as it can be, but it is too late in some cases. Patients have a reason then to feel short-changed. I would if I was in their situation and I certainly hope that I am never in that situation. To be left on a waiting list not knowing how serious is one's problem is not good. It does not help with having a good flow and effective treatment of patients in hospitals, and makes their stay longer.

There is significant frustration with the system. Two cardiology posts have been advertised in Kerry and are unfilled. One locum is in position. One geriatrician post has been advertised but the hospital has not been able to recruit for it. There is a vacant obstetric post filled by a locum. A radiology post has been advertised numerous times and cannot be filled. A half-time haematology post is vacant. A histopathology post has been transferred to Cork University Hospital. We have major recruitment problems and there is a knock-on effect for patients and stress for doctors and consultants. The Care Can't Wait campaign is about ventilating the real problem.

How? Just so I can help.

Mr. Martin Varley

We will do it through our Twitter campaign. I did an interview with Galway Bay FM yesterday. We need to engage with Deputies in their own areas, as is happening in Limerick. We have to be objective about the problems and make them known. We will appeal to Deputies to engage with the Ministers responsible in order that we do not see a repeat of an earlier discussion, where we asked why we were not having engagement on an issue that is win-win. My concern is that we are getting disengagement by official Ireland on one of the most important services that the population needs. Disengagement means that if a Minister does not meet one for seven months, despite repeated promises, then one has to call it out. We have a job to do and all of our members are frustrated.

I thank the witnesses for coming in and for their patience. Please excuse the pun. I thank them for their patience with the system as it is. I am almost fully aware of the challenges that they face every day. I seek clarity on a few things. The National Treatment Purchase Fund, NTPF, is often lauded. Yesterday was budget day and the fund had €100 million as of this budget, if my memory serves me correctly, having had €75 million last year. It is always lauded as being great that this spend exists. As some of the witnesses probably know, I work as a pharmacist at times but have worked in the hospital sector too. It seems that part of the health service is essentially subcontracted to a private company, whether in Dublin or abroad, and it is not as simple as just having a great value service. It is a success for somebody who gets an operation done abroad. Will the witness who is best placed to explain tell the committee and people at home what the impacts of that are? A person might get the operation but what about administration and follow-on care? It is an expensive way of doing business, from my reading of it.

Dr. Laura Durcan

In rheumatology, some centres have outsourced to the NTPF for basic, first-time assessments. In those cases, patients have gone to a private hospital for their first-time visit and if they are diagnosed with something or require further follow-up, they then go to the original unit as a return patient. That is dreadful for the person. The consultant in charge of that unit has not met the person who is now a return patient to the service with a rheumatological diagnosis. The same happens in many different places. It is something to be avoided for medical outpatients with conditions that need chronic care because it is a disaster.

I see many patients with joint replacements who have gone north of the Border or to other places to get their hips or knees done. It works really well for a young, healthy person who does really well with a hip or a knee and comes back saying it was fabulous and a great experience. Unfortunately, it becomes very difficult when somebody has a poor experience or does not necessarily do well with it. That person is then back in the public system with the complications of an operation that were done by somebody else.

Possibly in another jurisdiction.

Dr. Laura Durcan

Yes. With all due respect to my surgical colleagues, nobody likes cleaning up someone else's mess. It is difficult for those patients to then be cared for by someone with a surgical speciality who did not do the operation. That chronic care is a major problem for patients.

Last week, I had a lady in who had a knee operation in Santry under the NTPF. She came back in and said that she thought she needed to have her other knee done and really wanted it to be done in Santry. I said that I did not think the knee was that bad. She said that it would be two years before she got to Santry and asked if I would refer her now so that she can get into Santry in two years. I did not do that but it changes patients' expectations of how healthcare works. I think it is a very short-sighted intervention but it is necessary at times.

I know it is necessary but it bothers me that it is lauded as a good thing when I do not see it-----

Dr. Conall Dennedy

Could I follow up from what Dr. Durcan said about chronic care? I am an endocrinologist. We deal with diabetes, which requires a multidisciplinary care structure. We often hear of efforts to get people off diabetes waiting lists by referring them to the NTPF. If one tries to take someone off a diabetes waiting list and takes that person out of that multidisciplinary care setting, that person may be seen be a single consultant, the waiting list may be massaged, and he or she may be put on metformin or such. Individuals who are complicated patients may have been taken from a primary care situation and placed in that setting. Where do patients get their footcare and eyecare? What diabetes specialist nurse or advanced nurse practitioner can they ring up to adjust insulin should they be put on insulin? Those structures do not exist, for the most part, within private healthcare. Massaging a waiting list by taking somebody who requires that level of multidisciplinary care off the waiting list, by getting them a single visit to the NTPF, is not logical.

Mr. Martin Varley

We have moved from funding the NTPF for procedures to, more recently, outsourcing outpatient appointments. Set, contained procedures can work but our view is that we should mainly be using this funding to fund the capacity in public hospitals. Moving to outsourcing outpatient appointments, as we have heard from the two consultants present, is not really effective because the same patients come back in and need treatment in public hospitals.

Unfortunately, they will, in all likelihood, go back in at the end of the queue. It is a very cynical exercise, which does not deliver value for money.

I was speaking to a nephrologist in Tullamore, one of our main hospitals, earlier today. Normally that hospital has two nephrologists, but the second person took a post in another hospital. One nephrologist has been carrying the work of two for the past five years in Tullamore. The post has been advertised three times but there are no eligible candidates. The waiting list for an outpatient appointment is two and a half years, whereas the ideal is for patients to be seen within three to four months in order that urgent cases can be diagnosed. This type of scenario plays out all across the country; I am merely giving the committee a few vignettes to illustrate the problems. The situation is causing difficulties for patients, GPs and community services. Until we sort it out, the problems will spiral into greater problems throughout the whole health service.

Dr. Conall Dennedy

The National Treatment Purchase Fund figures for some of the waiting lists of which I have personal experience give an underestimation that is tenfold. I can give the Deputy examples after the meeting. In addition, one waiting list was quoted on the NTPF website as having a wait time of one year when, in fact, the actual wait time is a further two years and four months on top of that.

It is a long time to be waiting.

Dr. Conall Dennedy

There is somewhat of an underestimation in the figures given, particularly for endocrinology.

The delegates from the Medical Council provided the stark statement that more than 50% of non-consultant hospital doctors, NCHDs, are not in training posts. That is an extremely serious problem. When we are discussing waiting lists, different figures, and €20 million for this and that, the whole message can be lost. Will one of the witnesses explain, as concisely as possible, the impact of this particular situation? It seems to me that more than 50% of NCHDs are not wedded to the system. They are almost transient, taking their pay at the end of the week and going home and closing their eyes without a worry. On the other hand, there is a cohort of people working in the system for whom it is their whole life. Nobody does the job the witnesses do for a laugh. To my mind, it is a vocation. What are the impacts on the system into the future when more than half of the people involved are just doing the job and going home, as such? They are doing an important job but they are not in the system and helping to create a matrix that can be built upon.

Dr. Gabrielle Colleran

The Deputy has made an important point. On 25 September, a conference took place in University College Cork, organised by Professor John Browne, director of the SPHeRE research and training programme, to discuss the recruitment challenges for smaller hospitals. Professor Frank Murray, formerly professor of gastroenterology at Beaumont Hospital and now director of the HSE's national doctors training and planning, NTTP, unit, gave a presentation on exactly the topic to which the Deputy referred. Things have not always been as they are now. In 2010, for instance, only 30% of non-consultant hospital doctors were in non-training posts. This year, for the first time, that cohort is at more than 50%. It is a very bad situation to be in because when trainees are in training posts, they are affiliated to a college and faculty, take examinations and have training days, and can access a range of supports that come with being affiliated to a training scheme.

Moreover, the distribution of these non-training posts is not equitable, with smaller hospitals affected to a greater extent than the larger hospitals. The same hospitals that have a high proportion of empty posts, locum consultants and non-specialist consultants also have the highest proportion of non-trainee NCHDs in post. This leads to inequitable access to care for patients and an unsupported experience for the doctors in those roles. In order for a post to be a training post, however, there must be a permanent consultant in post who is a trainer. We have ended up in a horrendous chicken and egg cycle where we do not have enough permanent consultants to be trainers and not enough training posts. As a consequence, there has been an explosion in the number of non-training NCHDs. We cannot fill our permanent consultant posts, we do not have enough training posts and the hospitals are left desperately trying to cover the service and provide the care. That has to change.

Last week, I mentioned to the witnesses from the HSE the case of a consultant locum in Bantry who is on pay of €415,000, which is well above the contract pay. Is this an example of a post where no training is being done? As I understand it, that person walks into work and does the job but does not train any of the NCHDs.

Dr. Gabrielle Colleran

One cannot be approved as a trainer unless one is a permanent consultant. Only consultants on the specialist register can be trainers.

Is it fair to say that a shortage of permanent consultants in post at the top is having a trickle-down effect such that we are not breeding enough new hospital consultants?

Dr. Gabrielle Colleran

Yes. In addition, we are in breach of the World Health Organization's global code of practice on the international recruitment of health personnel. Under that code, any doctors who come here from designated areas of need should have equitable access to specialist training so that they can make appropriate progress and proceed to specialisation. That is not happening.

One of the witnesses from the Medical Council, Dr. Doyle, referred to that issue in her contribution. I raised it last week with the Minister but he did not seem to share my concern. Are we definitely in breach of the code?

Dr. Gabrielle Colleran

According to the Medical Council's workforce intelligence report, published in April, we are not compliant with the WHO's 2010 and 2016 recommendations.

We are taking from areas of need.

Dr. Gabrielle Colleran

Yes. We need to make our system self-sufficient. Enough doctors are graduating to provide our own pipeline and, equally, there are excellent doctors coming from abroad. The latter must have equitable access to training and specialisation so that when they finish, they can either go on the specialist register and become consultants here or will have acquired the excellence skills to do the same in their own countries. At the moment, we are poaching them and using them for service provision in smaller hospitals where they are not in training posts.

We are keeping the show on the road rather than building for the future.

Mr. Martin Varley

On the question of training and having sufficient numbers of consultants, some of the figures that were referred to relate to agency doctors. I know the background to this because we submitted a freedom of information request concerning the cost of agency doctors in certain hospitals where we knew people who are not specialists had been appointed in a temporary capacity through agency contracts. Not only are we paying them double the normal salary for consultants who are not new entrants and triple what new entrants are being paid, but those doctors are not specialist trained. That raises several concerns.

We have people in consultant posts who are locums and therefore getting two or three times the salary of the regular consultants even though they have had less training. That must have a negative impact both financially and professionally.

Mr. Martin Varley

Absolutely. It also is in breach of the Medical Practitioners Act, which prohibits persons who are not on the specialist register from practising independently. A consultant is described as a doctor who can practise independently. The HSE is well aware that it is in breach of its own guidelines in this regard. Proper supervised training cannot be provided by somebody who is not on the specialist register.

My next question is for Dr. Durcan. I understand that Beaumont Hospital has lost several dermatologists to the private sector, leaving only one permanent dermatologist in post. What seems to be happening now is that patients are essentially being subcontracted out to the people who used to work in the system. The seriousness of this type of thing sometimes gets lost in discussion. There is the idea when a person's knee is fixed or he or she is put on metformin, that everything is hunky-dory. The witnesses are working in the system and are worn out talking about the problems in it, as are we, but I am not sure whether people at home really understand how much these types of challenges can affect their lives. When staff are shed, as happened in Beaumont, there is a significant impact on patient care.

Dr. Laura Durcan

In the past year, we have lost three dermatologists, equivalent to two whole-time posts, to the private sector. There are several consequences for the service. The people who are not yet patients are the first to be affected.

Obviously there will no longer be anybody left in those posts to see new patients so we are left with the urgent dermatology referrals. Urgent referrals to dermatology are mostly query melanoma or skin cancer. Those are people who are really-----

They are worried.

Dr. Laura Durcan

They are really worried people and they should be seen very quickly and within a month. If a GP thinks a person has a melanoma then he or she should be straight in. We have a huge cohort of patients who are lesion query cancer. The second cohort of patients that are not being seen are the people with what I would call routine cases, but which are still horribly life changing conditions such as psoriasis, eczema and so on. Those kinds of chronic conditions also need to be seen in the dermatology clinic, but they are on the other side of the waiting list.

In addition to that we have the responsibility to patients. If a person is a patient of one of those people who have left, and if the patient is, for example, on a biological therapy for severe skin disease, or possibly on methotrexate - a form of chemo - for a severe skin disease, that person then has nobody to follow his or her progress over time.

Is the witness saying that as the consultant has left and gone to private practice the dermatologist has to continue the care of those patients, which can often be very complicated cases? All of the workload would then be channelled into the one consultant.

Dr. Laura Durcan

To be fair we actually have a huge issue in that we have nowhere to put a lot of those patients who are already on biological and chemo therapies. The service as it stands has nowhere to put those patients. We are having a huge change around to try to establish which patients are on the most toxic medications so we can pull them out and they can be seen safely. There is the clinical risk for those who have not yet been seen, which is huge, and there is also the clinical risk for those people who are already established patients of a service, who will also not be seen in their follow-up appointments. Both of those are really dreadful scenarios when someone leaves a post. It is what happens when any post is emptied anywhere in the country. This is what one is left with; the new cases and also all of the returned patients who have a diagnosis. It is dreadful.

I will, I am sure, be allowed to go on for some considerable time. Coming to the end of a discussion it is always different as there are more questions at the end-----

A few minutes.

I appreciate that. It was said earlier that politics should be taken out of medicine. Where did I hear that before? It has been ever thus, unfortunately. Think back to 2003 and 2004 when the health boards were abolished. The purpose of that exercise, according to the consultants with whom I had regular consultations at the time, was to take politics out of medicine and that it was going to work much better. It was not true. The consultants were wrong. It was the wrong diagnosis and they missed the point. It had nothing to do with it at all. The politics at local level in medicine at that time had the effect of gingering up the system and creating a combative approach within the system that everybody tried to deal with as best they could.

I am also concerned about another issue. In a previous presentation this morning there was a reference to bullying in the workplace. Unfortunately, consultants were mentioned in that context also. My question to the witnesses is how much of that goes on and why does it go on? In anticipation that the answer might be "when we are under stress we all tend to bully others", if that is the case then there would be an awful lot of bullying going on in here, and the Chairman would know this too. I want an answer to that please. There is no excuse for bullying in the workplace. It is illegal.

Dr. Gabrielle Colleran

In answer to the Deputy's question, Members are very well staffed compared to the European average for parliamentary politicians. The Deputy's situation is a little bit different from ours.

On the serious matter of bullying, which does exist in medicine and in medicine in Ireland, it is not just non-consultant hospital doctors, NCHDs, who are bullied even though the rates of bullying for NCHDs are slightly higher than for consultants. The rate of bullying of consultants is also very high. Who does it? It is other consultants, managerial staff, nurses, patients and families. It is totally unacceptable but it reflects a system that is toxic from within, and some of that is down to the fact that people are too overstretched. One may dismiss this as if it does not matter but there is a lot of research on burnout and its impact on people. The first thing that happens is dehumanisation. If one is overworked to the point of being mentally affected by it, the first thing that happens is that it becomes easier to be rude, to be mean and to be difficult with others because one perceives oneself to be under inappropriate stress. Is this what we want? Is this a system in which people flourish? No, it is not. Part of changing this requires us to change the culture and what is acceptable. It is about safe staff, a high quality and safe service, open disclosure and a just culture. All of this comes back to having enough people on the team to provide the service. Many of us are on rosters with half the number of people we should have. We are providing 24-7 care. Many of us here on this panel will be up multiple times during the night and will still have worked the full day the previous day and will work a full day the day after. Many of us are operating in situations where our workloads are far in excess of what is safe. We are constantly trying to protect our patients from risk, trying to train our NCHDs, and we come under huge pressure. Is bullying ever acceptable? No, it is not. Has it been a problem in our system for years? Yes it has. Many of us here display leadership in being the change we want to see for our own teams and our own NCHDs. We need to have enough staff on the teams to be able to provide the service safely.

I would suggest that somewhere along the line, the lines have become blurred. According to some financial experts Ireland has the third or fourth most expensive health service in the OECD countries. That is not speculation or surmise; it is a fact. Previously the question was answered on the basis that presumably we are spending the money in the wrong place. Of course, everybody would say that. We could all say that. The consultants representatives also said-----

Dr. Gabrielle Colleran

We specifically said-----

Wait a second now. I know the witness is anxious to give replies but tarry a little. We will wait and see. The then Minister for Health, Senator James Reilly, was named as the culprit in 2012. I am not certain as to whether any suggestion was made by the Irish Hospital Consultants Association as to how best that particular situation could be handled. Most of the country was broke, serious cuts were coming down the track, GPs had to make sacrifices and to accept cuts, judges had make sacrifices and to accept cuts, as did everybody right across the board. Nobody liked it and nobody wanted to do it but the then Minister for Health did not go out at that time and decide "I am going to punish the consultants, reduce their incomes and render them worthless". There is a danger here. I will not go along the path of my colleague, Deputy Alan Kelly, but he made the point that one can over-politicise medicine also. It is not necessarily in the interests of the patient, the consultants or the system.

I have one more point, and the witnesses can answer all of them then. Reference has been made to the State Claims Agency and a dramatic increase in recent years of €184 million per year. That is not unique to the health services. The State Claims Agency in Ireland and its equivalent in other jurisdictions have had the same problem. I can get the figures on those if the witnesses wish. I am concerned that it is very easy to throw out the figures and say "Look, this is the cause of our problem and we need more money". Everybody needs more money. Has the Irish Hospital Consultants Association considered how much more money consultants need to deliver the services that the witnesses say they need? I agree. Can the witnesses can tell me the amount of money they need? Is it €3 billion? Is it €4 billion? Is €10 billion or €20 billion?

Mr. Martin Varley

I thank Deputy Durkan. We touched on some of these issues during our last exchange with the committee and I thank the Deputy for raising them again.

The reduction imposed on new entrant consultants in 2012 was an additional 30% on top of the 10% for new entrants. It has never saved money, for reasons I can point to. We have longer and longer waiting lists. We are outsourcing more than an extra €100 million next year. Our agency bill has gone up to €90 million. That is the medical agency only, which is an increase of more than €60 million. Our cost of indemnity has quadrupled, and I only quote the cost of clinical indemnity that the State Claims Agency is responsible for. If one compares this internationally, our costs of indemnity are much higher than any other jurisdiction. There are a variety of reasons for this. I am quite sure that our low staffing is a contributory factor. A recent Medical Council report on training counts found that where trainees were working long hours - as often happens with a 50 or 60 hour week - there is quite a high incidence of being involved directly or indirectly in an adverse incident concerning a patient.

There is a correlation which the statisticians will see if they wish to go and do the work. It is common sense that understaffed teams will lead to more clinical indemnity problems and that longer waiting lists will cause more adverse outcomes for patients. We are dysfunctional in how we are managing the health service, not in how we are delivering it. There are excellent staff on the front line who are doing their absolute best in extremely difficult circumstances. The decision by Dr. James Reilly was not justified at the time and no other group of public servants was singled out for such a cut. There was a related but not equivalent cut for the Judiciary, but it was reversed in full earlier this year. One group of public servants has been left with a salary differential of between 30% and 40% and it is the one with the biggest recruitment and retention problems. We want to engage with the Minister and have been seeking a meeting with him for the past seven months. Making progress involves engagement. When officials and the Minister do not sit down and engage with the body which represents 95% of consultants, we know that there is a problem. The problem is not with the consultants who are seeking the meeting but with those who are not engaging.

The amount of money required to run an efficient and effective health service is multifactorial and we do not have the manpower to analyse it. We spend €1.23 billion less in Government funding on public hospitals than the EU average and have the lowest numbers of beds and consultants, with the highest bed occupancy. In running any service such indicators would be used as guidelines in progressing and solving the problem. We need to redirect funding to the front line to deliver care, meaning that acute hospitals and mental health services have to be funded appropriately. The mental health service is very poorly funded by international comparisons, as are acute hospitals. We want to sit around the table and work through these issues, but we are not in a position to tell anybody what the health service requires by way of funding for the future, as thousands of public servants are paid to do that job. I was a public servant once, but I do not have to do it any more as I am preoccupied with a far wider brief. I hope the public servants to whom I refer are prepared to meet us to brainstorm on the issues and come up with solutions.

I cannot compete with Deputy Donnelly who made an offer to alleviate some of the budgetary concerns, but I am sure we will relay to the Minister the association's anxiety to progress matters on an amicable basis and I am sure he will respond in kind. I cannot determine the outcome, but if the two sides are engaged, I am hopeful there would be some outcome. I have a couple of more questions, but I do not want take away from the answers.

I am afraid that the Deputy has run out of time.

Dr. Gabrielle Colleran

The Deputy asked how high the overall health spend was relative to other countries in the OECD. The €4.5 billion spent on acute hospitals is well below the figure for the OECD. Mr. Varley was asked what was needed to provide a service. I would compare Ireland with Scotland in that context. Representatives from the Scottish system visited us recently and had a very productive meeting with the Minister for Health. It has twice the number of consultants and 30% more beds. I ask the Government to give us the staff and the capacity to enable us to do our jobs. We do not want to be here throwing stones at the Minister; we want to work with the committee, to be leading, innovating and providing care for patients, for whom we are responsible.

That is why I asked the question. It would be helpful if the consultants could give us some indication of the extra money required. There is a myth which I have heard many times that one can pour money into the system and nothing happens. I do not agree.

Dr. Gabrielle Colleran

We have seen a large increase in the number of managers. We need to see an increase in the numbers of front-line staff treating patients. We have the lowest number of consultants in Europe and 20% of posts are empty, while we also have the longest waiting lists. The two are connected. I call on the Government to staff our teams to let us do our jobs. We want to deliver a real good news story in the health service in collaboration with the committee because we are all on team health.

Mr. Paul Reid, director general of the HSE, has committed to balancing the books. The overrun in the health service this year will be €310 million lower than last year, if one is to believe the figures included in the Budget Statement yesterday. Something must have happened to reduce spending to that extent and I would like to know what it was, although I am not asking the question of the delegates today. One worries that the reduction has led to an increase in unmet needs. We are trying to find solutions. If the director general of the HSE is to balance the books, services must be reduced or the system reformed. Can the delegates demonstrate to the Minister that a restoration of consultant numbers and pay parity would reduce costs to the health service? Can they demonstrate a relationship between restoring pay parity and saving money in the health service? The HSE's service plan will be delivered in the next three or four weeks. It invariably starts off with a statement to the effect that the money the HSE has been given this year will present challenges in delivering services similar to what was delivered last year, as well as in coping with innovation and the development of services. A winter initiative will also be presented in the next few weeks. It will include the cessation of elective care in December and January in order to free up beds. That will lead to longer waiting lists. Will the delegates comment on the association's campaign for pay parity in the context of delivering cost savings to the HSE?

Dr. Gabrielle Colleran

Since 2012, when the recruitment and retention crisis started, the medical agency locum bill has gone up by €57 million per annum. Therefore, there are savings to be made in that area alone. There are always background expenses related to providing sick cover and maternity cover, but addressing the locum bill could generate huge savings. However, there are things that are harder to quantify such as the savings to be made in seeing and treating patients earlier. In the context of Mr. Reid's attempts to balance the books, I ask everybody to give him a chance. If he goes to the Department of Public Expenditure and Reform for additional funding, the fact that there has already been so much additional funding while waiting lists have got longer will make it more difficult for him. He has had a few meetings with multiple consultants and senior leaders in nursing and midwifery, as well as allied health professionals, to discuss how we can save money without impacting on patients. The impression I get from him is that he wants to show that he has a stable pair of hands and can manage the money in order that he can have investment where it is needed. As consultants, we want to see that cost savings are not made in providing patient care but in eliminating waste within the service. In any healthcare system across the world there is 30% waste. Consultants are very keen to lead in that regard. Dr. Durcan is involved with biosimilars which enable us to save money without an impact on patients as the priority is to ensure patient needs are met.

Dr. Laura Durcan

We calculate the figure for restoring pay parity at around €20 million. Therefore, taking it from the agency or locum bill, to get people in posts and have service development for patients, should be better than cost neutral. We are selling the proposal as cost neutral, but we could actually save money on the locum bill, though I am loath to say that before it happens.

It should be possible to balance those.

In rheumatology, dermatology and gastroenterology, we use quite expensive biological drugs which cost a huge amount of money. There has been a HSE initiative to bring on a biologic hub where one electronically prescribes these medications. The HSE has put forward this programme where we prescribe biosimilars, which is similar to the concept of generic prescribing. One prescribes the slightly cheaper version. In return for that, the Government has set out that the units will be rewarded with a once-off payment in order to facilitate this kind of process. The Irish Society of Rheumatology and my hospital will weigh in on this.

The truth, however, is that people want to weigh in in a scenario where they have a good relationship. Rheumatology is full of nice people who want to help but there are other specialties which will kick back against this type of initiative. There are many of my colleagues who do not want to engage in a process where they see a system that is flogging them to death but gives them nothing back. It is undervaluing them and chasing them away. If one has a system where one engages with the lead players to give patients the best service they can have, then it is a relationship that works both ways. There are huge cost savings which we had in many different places. At the moment, however, we are all operating in silos and we think those outside them hate us. We may not be as facilitating as perhaps we could be. That is being honest.

On the employment of a locum or a temporary consultant compared to the employment of a permanent consultant, will the witnesses quantify the quality of care provided between those two different employments? Surely the continuity of care with a permanent consultant delivers much more coherent and long-term quality of care than even the best-intentioned agency consultant or locum. That must have an effect on patient care.

Dr. Gabrielle Colleran

There is a huge value in permanent staff who are invested in a hospital, in a service and in a patient population. Somebody who is planning to spend the next 30 or 40 years working in an area is invested in looking for resources, as well as innovating, leading and bringing in the newest changes. We have many excellent locums. However, when one is transient, clocking in and clocking out, one is doing a clinical service job but one does not have the commitment to the education, the research or the quality improvement, namely, all those elements that consultant leadership brings. Importantly, one is not a trainer.

One of the most important points going forward concerns our next generation, our excellent medical graduates who are wanted everywhere in the world. Dr. Rita Doyle has been a magnificent advocate for non-consultant hospital doctors, NCHDs, and for all doctors. She describes interns as the jewel in the crown. We want our interns and NCHDs to see a future, leading and innovating within our health services. It is important we really tackle this now because we are at a tipping point. One in eight of the population is over 65 years of age. By 2030, it will be one in six. There will be a shortage in Europe of 200,000 doctors by 2030. We need to hold on to our people.

We keep replacing the doctors, however. We really need to fix our system to ensure our brilliant NCHDs want to work in our system. Deputy Alan Kelly has left the meeting. UHL and smaller hospitals around the country are at a tipping point. I will not name the hospitals but there are some where the majority of consultants are either locums or non-specialists, as well as the majority of their NCHDs in non-training posts. This is a health apartheid and it has to be tackled. Until ten years ago, we had excellent physicians wanting to come back and work in these hospitals. These are wonderful communities which are paying the same taxes. They should expect the same access to health care. We really have to fix this.

In general terms, is it the case that a locum or an agency doctor brings no added value to the system?

Dr. Gabrielle Colleran

In general terms, yes.

Dr. Donal O'Hanlon

I think they are much less efficient as well because they do not know the patients or the system and they move quickly.

Dr. Gabrielle Colleran

They also order more diagnostics generally, meaning that it is much more expensive.

Dr. Aine Burke

I work in the north west. My hospital and other local hospitals are routinely staffed with locums. I do not want anyone thinking that locums do not provide good quality care at the coalface. At the moment, they are plugging a necessary gap.

However, the Chairman is correct that the biggest deficit we have is in the continuity of care for individual patients. If one has not met a patient in clinic before, one is less likely to discharge them and more than likely to bring them back in six months. This is because one does not really know them and not entirely sure if something might have been missed. The next locum comes along and something similar happens. This speaks to the efficiencies within the service.

I took up a post as a permanent consultant several years ago. I do my day-to-day job but I also sit on several hospital committees. A temporary appointment in a hospital will not take on such roles, however. They will not get involved in drugs, therapeutics, policy-making decisions, clinical protocols, etc. Those are the matters which really make a difference on a systemic level. Locums can look after individual patients but it is not a way to run a service.

Dr. Conall Dennedy

On the point of training and academia, I am going to bang the academic drum.

The three shields of medicine are that one provides absolute excellent care for one’s patients, one innovates to provide the best care for the future for one’s patients and one trains the doctors of the future. The last two require senior well-qualified individuals in permanent posts. Somebody in a permanent academic post can, over the period of their career, bring in €20 million to €30 million in non-Exchequer training and research funding to train doctors for the future. This is future planning and providing care for our doctors for the future.

Take the example of the ICAT programme, a group of eight physicians got together and applied to bring in €16.5 million in non-Exchequer funding from the Wellcome Trust. This programme funds doctors to do PhDs to be the academic and medical leaders of the future. While also providing fantastic healthcare, it leaks into our academic system and universities whose falling rankings we should be trying to increase as well. We have not mentioned medical students. We want to teach them to become the doctors for the future, as well as to become the excellent consultants, clinician scientists and academics we need for the future to provide cutting-edge healthcare for our patients.

Mr. Martin Varley

In a business-like sense or an economic sense, we have been talking about improved efficiency, effectiveness and productivity. Based on the budget, we spend about €5,000 million on acute hospitals. Most business people would say that it is not beyond the stretch of capability to introduce a 1% productivity efficiency gain which, as it happens, is €50 million. This is way above the cost of putting the people in place on a permanent basis.

The effectiveness and benefit of having permanent staff compared with serial locums cannot be underestimated. I am quite sure we are missing out on significant productivity and effectiveness gains by the way the service has evolved since the inequity and discrimination was introduced with these posts which were filled on a temporary or an expensive agency basis.

The maths on this is absolutely certain. We have a situation we can resolve. It would be better than cost-neutral when one looks at the benefits and cost savings. I cannot understand why official Ireland is not engaging to do the necessary.

Our members have remained a long time here this morning.

As have our guests.

Yes. I should have offered them an opportunity to take a break.

They are a hardy bunch.

I suggest a quick round of one question each as we have to vacate the room in ten minutes.

My question relates to consultants who are not on the specialist register. Dr. Colleran described a scenario in some hospitals where we have gone over the 50% threshold of non-specialists plus locums. Will Dr. Colleran detail for us the potential impact of this? I am referring to the context of non-specialists who, because they have a lawful entitlement to a contract of indefinite duration, work and are paid as consultants but are not eligible to be entered on the specialist register.

The HSE has advised that there are no specific supervisory arrangements in place for this cohort of workers. Of course, how could there be? My reading is that precious little is being done to convert them or address the situation. Are the witnesses aware of any supervisory arrangements, specific or otherwise? There have been varying responses from the HSE. What is the impact on the ability to innovate and deliver a service of them not being on the specialist register? I am not suggesting that they are not working, since they are.

Dr. Gabrielle Colleran

The Deputy's point relates to the definition of a consultant, which is a specialist consultant on the specialist register who is capable of independent practice. The Deputy asked whether we were aware of a method of supervision for those who were practising as consultants but were not on the specialist register. No, we are not.

My parents-in-law are from Kerry. If they go to their local hospital and see someone with a consultant badge, I expect that that person is, by definition, on the specialist register. What being on the specialist register means is that someone has gone through the appropriate training scheme and passed the relevant examinations. There is a minimum standard that he or she has met. If someone is not on the specialist register but is on the general register, the minimum it means is that he or she has passed an internship. However, there can be a large discrepancy in what examinations they have passed and what experience they have. For the public, it is false advertising if someone has a consultant badge and is not actually qualified in that way. Speaking as someone with family outside Dublin, my concern is that the numbers are not spread evenly across our acute hospitals and are mainly concentrated in pockets. I will not name the hospitals, but committee members could probably guess them. It is a concern that there are pockets where there is a lack of permanent consultants, locums and non-specialist consultants who are not on the specialist register are in place, and the majority of NCHDs are not in training posts. That is not the desired mix for a high-quality and safe service for patients. Everyone in Ireland deserves timely access to a high-quality service. We have to do better than this.

To be fair to the hospitals in question, they are desperately trying to provide the medical care that is needed. When they do not have the qualified staff, they are faced with a choice between whether it is riskier not to provide any care or to have the care provided by someone who is not fully qualified to provide it independently. I do not know of research in other countries into this question, as other countries do not do this.

That is the key - it is not done elsewhere, so it could not be considered best practice internationally or otherwise.

Dr. Gabrielle Colleran

Similar to our waiting lists, I cannot get advice from other specialists in my specialty in other countries on how they triage their waiting lists. When I speak about waiting lists, they ask whether I mean longer than six weeks.

I thank Deputy O'Reilly and Dr. Colleran.

Let us go back to where it all started with the then Minister, Senator Reilly. I am actually a big fan of the Senator. As Deputy Durkan stated, the country was on its knees. We all accept that. It was not just the Judiciary and the doctors, as pharmacists took a similar cut. It had a massive impact on the sector. That took the form of a reduced pay bill, but the long-term impact has been far greater. It was essentially a false economy. We had to balance the books at the time.

The impact of what we discuss in the Houses is sometimes difficult for people at home to understand. Dr. Colleran has mentioned a person's expectation that the consultant his or her mammy meets in Tullamore or wherever is a real consultant. We are all of an age to remember the yellow packs. We do not want a devalued, inferior or two-tiered consultant.

It was always the case that doctors left college, entered the system, trained up and wanted to be consultants "when they grew up". I am not trying to trivialise it. As such, it is concerning that people are not even applying for jobs anymore. A question has been asked about how much money is needed. Some €20 million has been requested for the restoration of pay, which would to some extent encourage people back into the profession and even out the differential between private pay in private hospitals and the public contract. Although Sláintecare commits to removing private care from the public system, my understanding is that, when the 2008 contract was negotiated, it was to ensure that a consultant was not disadvantaged by working in the public sector. The contract was designed so that a consultant would not just leave to work in a private hospital.

Dr. Gabrielle Colleran

In terms of the retention of staff, the public sector should pay the lowest amount possible that retains the staff in the public sector. Currently, there is a leakage of specialists from our public sector to our private sector.

Dr. Gabrielle Colleran

In Cork city, 13 specialists left within a two-year period to go to the private sector. The market has spoken and the current policy is not working.

It is a runaway train at this stage. I do not mean to be dramatic, but I am concerned. I have read much of the material the witnesses have supplied. We are clearly not breeding a new cohort of consultants, given that we are not training them. If we are not paying them, they will stay abroad or go to the private sector.

Senator Burke often speaks about the differential in the recruitment of front-line staff versus managers. If we are top heavy, what is the witnesses' view on the manager idea? Is it to manage consultants? What is the logic behind there being so many administrative staff and others in the system who do not cure or fix anything? Is it an anti-consultant attitude, as in, consultants are always asking for things but they are grand really? Why is the HSE placing more value on managers than people like consultants who can fix illness?

I thank the Deputy.

We will get an answer.

Dr. Gabrielle Colleran

We cannot answer for HSE policy, but when Mr. Paul Reid spoke to us at our conference, he was clear that he knew he needed more consultants in the system and that we were very much a part of the answer to solving many of the problems in the health service.

That seems kind of obvious. I am not being smart, but one cannot run a service without doctors. He was just stating the obvious. How is the HSE going to address the constant issue of the manager being over the medical person?

Mr. Martin Varley

We have to be fair to all grades of staff in our hospitals and the wider health service. They all do an excellent job.

I am not suggesting they do not.

Mr. Martin Varley

I know, and I am not suggesting-----

I worked as a cleaner in a hospital.

Mr. Martin Varley

I am prefacing what I say-----

I understand all the way down through the system works.

Mr. Martin Varley

Exactly.

I am not suggesting otherwise for one minute.

Mr. Martin Varley

I know that, and I was not suggesting it either. I was prefacing what I was going to say in case I was misinterpreted. We have probably layered up management and administration by default over a series of reconfigurations and policy changes and by virtue of the fact that a proper effort was not made to determine how the service could be restructured possibly. We could point to the change from the health boards to the HSE. By the way, Deputy Durkan, the IHCA did not seek that. In our most recent documents, we have encouraged an integration into regional areas where hospitals and community services would be put together. Our main ask therein is for one streamlined team and one budget, for community services and hospitals to work together and for bureaucracy to be delayered. This is not intended as a criticism of anyone who is in administration or management, but we have six administrative or management personnel for every consultant. That is too high by international standards. The fault rests with the failure to restructure, not the individuals. The individuals probably do a very good job but, given the significant change in IT services, some of those functions and jobs may need to be redeveloped such that we would have less administration and less management. This is where we can work together. We can spend the money we have better, though. There is no doubt about that.

I thank Mr. Varley. I invite Deputy Durkan to make a final comment before we wind up proceedings.

I am not sure what I can say that I have not already mentioned as regards structures, but I should remind everyone that I was a member of the special health committee that eventually developed Sláintecare. One of the points that I made time and again was about the need to revert to original structures where there was local accountability and, as staff throughout the health services have indicated to me for many years, they got more satisfaction and were more dedicated. I did not get what I wanted because everyone did not agree. It was an all-party committee and it can be very difficult to get a committee to agree. That is how the camel was invented in the first place.

However, we did get some part of what we wanted and there are regional structures in place. I hope that will work out, with the benefit of local knowledge and a response at local level. It cannot be done without that aspect. Some of my perspective on this comes from my experience as Opposition health spokesperson in very difficult times.

The final point I wish to raise is one I have raised on many occasions in the past. It relates to the ability, or lack thereof, to make a comparison between a private hospital and a public hospital within the system, size for size, consultant for consultant, doctor for doctor and so on. Somebody should be able to tell me what the cost is of running one system as opposed to the other. When I tried to engage in that discussion over the years, I was repeatedly told that the public sector is more expensive. I cannot understand how that is the case.

Dr. Gabrielle Colleran

Of course it is.

Dr. Colleran will tell me that there are certain ancillaries that have to be dealt with, but I am talking about a one-for-one comparison. I would love to know the answer to that question, as I am sure the Chairman would too.

Dr. Laura Durcan

In terms of the complexity of care, we need to look at the patients who come to a hospital before considering any bed-for-bed cost analysis. It is a question of patient morbidity, that is, how sick they actually are. Any analysis that looks at the cost per patient or cost per hospital stay must be adjusted for comorbidities. The patients who present to us in the acute hospitals are astonishingly more unwell than the patients who present to most of the private hospitals, mostly because the former present in a crisis via the emergency department. These are people who have a comorbidity list of 20 illnesses and are taking numerous medications. It is not the same patient population presenting to the private hospitals as that which presents to public hospitals. As a result of paper-based record-keeping, as one factor, we are not very good at capturing the degree of complexity and comorbidity we are seeing in the public system. That is very much reflected in the cost of a patient stay in the public system versus the cost in the private system. It is a huge factor.

Dr. Gabrielle Colleran

The patient profile is totally different as between public and private hospitals, such that one is not at all comparing like with like. Public hospital emergency departments must be sufficiently staffed and have the capacity to treat any emergency case that presents. Such cases would include a person who has had a stroke or brain haemorrhage or is presenting acutely with a tumour, as well as people involved in a serious road traffic accident who might need to see a vascular surgeon, neurosurgeon and orthopaedic surgeon. All of those specialists must be there to provide care in the middle of night, with access to anaesthetic services and an intensive care unit. Within the private sector, on the other hand, hospitals can cherry-pick the types of care they provide. To illustrate, I will use the example of a private MRI scanner. A private hospital providing a musculoskeletal MRI service might have 20 young men with sore knees in and out at a cost of €200 each. In Holles Street, on the other hand, we have very sick and intubated premature infants coming down for MRI scans, accompanied by senior nurses and neonatologists, with each such infant possibly spending an hour and a half in the scanner. If we compare our scanner with the scanner in the private hospital, the latter will seem to be much more productive because it was used for the young lads who were able to hop on and off in quick succession.

In fact, we are providing complex, high-level care and, as such, we will always be more expensive. However, if one is pregnant, if one is a child, if one is in a road traffic accident, if one has a stroke or a brain tumour, one will not be going to a private hospital but to one of our public hospitals. We need to be adequately staffed and have the infrastructure to provide that care. When one needs an intensive care bed in a public hospital, one does not join a waiting list.

There are some private hospitals advertising the same services to which Dr. Colleran referred. I will not name them because we all know which they are.

Dr. Donal O'Hanlon

That cannot be the case. Whether one likes it or not, one cannot make a like-for-like comparison between private and public hospital care provision. We have spoken today about balancing the books in terms of pluses and minuses. We probably need to look, too, at logistic regression, a range of confounding variables and projections and very complex health economic models. The demographic and socioeconomic status of the two groups of patients who come to the two different types of hospitals must be taken into account, as well as the acuity of each type of patient, the case mix and the requirement for multiple models of multidisciplinary care for the different patient groups. The differences are such that one cannot make a direct comparison between them. It would simply be bad economics and bad research to do so. Indeed, if a research paper came to me as a reviewer which contained that type of comparison, I would reject it.

Whatever about the bad economics part of it, my question will remain unanswered today. We will have an opportunity at some stage in the not too distant future of meeting some of the people in the private hospitals, at which stage we may be able to revisit the situation with mutual benefits.

We are over time and must conclude. I thank our guests for attending. We will be discussing this issue with representatives of other organisations in the coming weeks, after which we hope to produce a report on our deliberations.

The joint committee adjourned at 1.45 p.m. until 9 a.m. on Wednesday, 16 October 2019.