This meeting will involve a discussion with officials from the Department of Health and Children and the Health Service Executive on the filling of consultant posts. I welcome Mr. Bernard Carey, Mr. Denis O'Sullivan and Mr. David Maguire from the Department. I also welcome Mr. Tommie Martin, Ms Fionnuala Duffy and Mr. Martin Rogan from the HSE. I ask the witnesses to begin their presentations. Members are free to ask questions thereafter.
Filling of Consultant Posts: Discussion with Department of Health and Children and HSE.
I thank the Chairman and the rest of the members of the joint committee for this opportunity to make a presentation on the filling of consultant posts. There are 2,144 approved consultant posts in the health service. This represents an increase of 852, or 66%, since 1997. The total pay bill for consultant posts is approximately €306 million. The current number of vacant posts is 331, or 14% of the approved workforce. The terms and conditions which apply to consultants are set out in the 1997 consultants' common contract. As of 30 November 2006, the basic salaries of consultants ranged from €139,000 to €173,000 for non-academic consultants, and to €222,000 for academic consultants at professor level. In addition, consultants can earn up to €22,000 in on-call payments.
I would like to comment on the regulation of consultant posts. Prior to 1 January 2005, Comhairle na nOspidéal, which was established by ministerial regulations made under the Health Act 1970, was responsible for regulating the number and type of hospital consultants. Its responsibilities included, inter alia, responding to a hospital’s request for a consultant post by assessing service needs and verifying that the request was valid. The Department of Health and Children played a role in this process by ensuring that qualifications were correct and providing sanction and funding for posts. In line with the provisions of the Health Act 2004, Comhairle na nOspidéal was dissolved on 1 January 2005, which was the establishment day of the Health Service Executive, which assumed responsibility on that date for the assessment, approval and funding of hospital consultant posts. Recruitment to consultant posts in voluntary hospitals is handled directly by individual hospitals. The recruitment process in HSE hospitals is conducted through the Public Appointments Service, which was established under the Public Service (Management and Appointments) Act 2004, which allows the HSE to apply for a licence to recruit consultants directly.
I understand that the joint committee has a particular interest in the filling of consultant posts in neurology and in cystic fibrosis services. The 2003 Comhairle na nOspidéal report on neurology and neurophysiology has been the blueprint for the recent development of neurology services. The report recommended the priority appointment of 15 new neurology consultant posts; the subsequent appointment of an additional ten consultant posts, making a total of 25 posts in the long term; and the appointment of an additional six neurophysiology posts. It proposed that clinical neurophysiology services should be based at the two existing neuroscience centres at Beaumont Hospital and Cork University Hospital and that further services should be established in University College Hospital in Galway.
Funding of €3 million was allocated to the HSE in 2006 for the development of neurology and neurophysiology services. A further €4 million has been provided in 2007 for the development of neurosciences. The HSE is conducting a national neurology needs assessment to seek to identify clearly the health system's current provision and future requirements in respect of neurology services. The key priorities for 2007 that have been identified by the assessment group, which has multi-sectoral representation, reflect the recommendations of the 2003 Comhairle na nOspidéal report on neurology and neurophysiology.
The need to develop services for people with cystic fibrosis has been widely acknowledged. The Cystic Fibrosis Association of Ireland commissioned Dr. Ronnie Pollock to review hospital services for cystic fibrosis in the context of accepted international standards. The report, which was published in 2005, provided an assessment of need for current and future cystic fibrosis patients and made recommendations about the numbers and categories of staff that are appropriate for a modern and multidisciplinary cystic fibrosis service. The report concluded that cystic fibrosis care should be provided in fewer units of a more significant size so viable staffing levels can be maintained and staff can have a workload that is sufficient to maintain their skills.
The Minister has identified the enhancement of services for people with cystic fibrosis as a key priority. In advance of the working group's report and as an acknowledgement of the immediate need to enhance services for people with cystic fibrosis as identified in the Pollock report, funding of €4.78 million was provided in 2006 to facilitate the recruitment of additional consultant, nursing and allied health professional staff to improve services for cystic fibrosis patients. Additional funding of €2 million has been allocated this year, as part of the overall funding for health services, to facilitate the further development of cystic fibrosis services and build on the investment provided in 2006. Following the publication of the Pollock report, the HSE established a working group to undertake a detailed review of cystic fibrosis services. The Department understands that the group's report makes recommendations on a range of service improvements needed for people with cystic fibrosis. In particular, it refers to the need to increase the level of clinical, nursing and allied health professional staffing in cystic fibrosis units throughout the country.
My colleagues and I will be pleased to answer any questions the members of the joint committee might like to ask about the Department's role in the process of filling consultant posts.
I thank Mr. Carey. I invite Mr. Tommie Martin of the Health Service Executive to address the committee before we take some questions.
I thank the Chairman and the other members of the joint committee for inviting the Health Service Executive to address the committee on the filling of consultant posts. In my presentation, I will outline the stages which are involved when decisions are being taken on the need for a consultant post and the subsequent filling of that post. Like my colleagues, Ms Fionnuala Duffy, who is from the National Hospitals Office, and Mr. Martin Rogan, who deals with mental health services in the HSE, I will be happy to deal later in the meeting with the committee's questions on this matter.
Pursuant to the Health Act 1970, Comhairle na nOspidéal regulated the number and type of appointments of consultant medical staff and specified the qualifications for such posts. As a former member of Comhairle na nOspidéal, Senator Henry will be aware of these matters. Comhairle na nOspidéal was dissolved pursuant to section 57(1) of the Health Act 2004 and its regulatory functions were transferred to the HSE pursuant to section 57(2) of that Act. The Public Appointments Service is responsible for the process of recruiting people to consultant posts in HSE hospitals and mental health services. Voluntary hospitals, such as the Mater Hospital, Beaumont Hospital, St. Vincent's Hospital and Tallaght Hospital, as well as voluntary agencies like St. Michael's House, undertake their recruitment processes separate to the HSE recruitment process. A consultant can be appointed to a post in the HSE, a voluntary hospital or a mental handicap agency like St. Michael's House following formal approval from the HSE.
I will speak about the current governance structure. Under section 57 of the Health Act 2004, certain functions relating to the regulation of appointments and the specification of qualifications for appointments were transferred to the Health Service Executive with effect from 1 January 2005. These statutory functions cover all consultant appointments in publicly-funded hospitals and agencies, both HSE and voluntary, regardless of whether the posts are additional or replacement, or permanent or temporary. The HSE has no role in the staffing of private hospitals, however. The board of the HSE, which is its governing body, has responsibility for the performance of the functions assigned to it under the Health Act 2004 or any other enactment. The board has delegated its functions to the chief executive officer, with the exception of a number of functions it has reserved for itself, in line with standard practice. The chief executive officer has delegated responsibility for the performance of its functions under section 57 of the Health Act 2004 to me as the national director of the office of the chief executive officer. I am, therefore, responsible for the regulation of the number and type of consultant appointments in the publicly-funded health services and for the specification of qualifications for consultant medical staff.
The HSE has established an interim consultant appointments unit which replaces Comhairle na nOspidéal and processes consultant applications. Former Comhairle officials, now assigned to the HSE, with relevant expertise and experience in this area have formed the core staff of the unit. The unit communicates regularly with officials in the HSE, especially the national directors of the National Hospitals Office; the primary, community and continuing care directorate; human resources and senior planning officials in carrying out these functions. Advice is also sought, as required from postgraduate medical training bodies such as the College of Physicians, Royal College of Surgeons Ireland, the Irish psychiatric training committee, etc.
Consultant appointments can arise in a number of ways, including the need to replace an existing post-holder who has retired or resigned, or in response to service developments identified in the HSE's national service plan which outlines how the HSE plans to achieve its priority objectives in a given year. The service plan outlines the HSE's plans to develop various services such as neurosciences, renal services, mental health services and services for older people. Associated with these developments is a range of new staff which often includes additional consultant posts. Each application for a consultant post is initially drawn up by the applicant hospital or agency. A considerable amount of detail is required, including the weekly duties for the post and detailed workload data.
In the case of consultant appointments which fall within the ambit of the National Hospitals Office, representatives of the hospital or agency discuss the application with the appropriate HSE hospital network manager. In the case of specialties within the ambit of PCC, such as psychiatry, palliative medicine, community paediatrics, and geriatric medicine, the representatives discuss the appointment with the appropriate local health office manager for primary, community and continuing care. The application may be altered or refined at this stage.
The relevant hospital network or LHO manager must approve and sign the application and forward it to the HSE's interim consultant appointments unit for consideration. Applications are considered by the interim unit in the context of published Government policy on the health services generally, specific hospital services, the approved HSE service plan and published reviews and reports on specific specialty areas by the Department of Health and Children, the HSE, Comhairle na nOspidéal and other bodies. Each application must include an outline of how the post fits in with relevant national, regional and local policy.
The assessment process also takes into account demography, professional advice, precedent, literature review and relevant local information. Following initial consideration by officials, clarification on specific aspects of an application may be sought prior to proceeding with further consideration. Availability of funding and alignment of the post with the service plan is confirmed by planning officials in the NHO or PCC depending on the nature of the post. These officials include Ms Fionnuala Duffy and Mr. Martin Rogan who are in attendance with me today. Officials in the HSE directorates of finance, human resources and population health are liaised with regularly as required.
Applications are considered on a monthly basis to ensure a quick turnaround. The HSE's approach seeks to ensure, as far as possible, that each appointment is structured in such a manner as to constitute a viable job which is likely to adequately serve the needs of patients and the hospital or hospitals concerned and to satisfy the appointee from a professional viewpoint. In addition to the direct patient care duties, teaching, research and administrative commitments are also taken into consideration. Decisions are made with the objective of providing high quality, safe health services in the context of Government policy, HSE service requirements and available funding.
When a decision is made to approve a post, an approval letter is issued by me to the hospital network or LHO manager or the CEO of the relevant voluntary hospital or agency. The letter includes details relating to the post including the title, specialty, sub-specialty, if any, location of sessions and the requisite professional qualifications, training and experience. The approval letter is the basis of the job description and duties for the post and forms part of the consultants' contract to be signed by the consultant appointed to the post.
The average time taken to approve consultant posts from the date of receipt of completed applications is two months, though many are approved within one month. Approximately 10% of applications — a small proportion — can be delayed for significant periods for a variety of reasons including major policy issues regarding location, viability, duplication and lack of clarity. Sometimes applications are not in line with national policy or the HSE service plan.
Applications to replace consultants who have retired or resigned are subject to the same procedures. A retirement or resignation presents the HSE with the opportunity to review posts in the context of service developments and changes in medical practice and specialties. The HSE encourages succession planning in the consultant workforce, suggesting that hospitals and agencies submit applications for replacement posts arising from the anticipated retirement of incumbents at least one year in advance to ensure that interruption to consultant services due to retirements is minimised. This advice is not always followed.
The recruitment process does not involve the consultant appointments unit. Once an approval letter has been issued, the recruitment process may commence. In the case of consultant posts at voluntary hospitals and agencies, the process is undertaken by the hospital or agency itself. In the case of consultant posts based at HSE hospitals, the recruitment process is undertaken by the Public Appointments Service. Once a consultant post is approved, the average time taken to fill it is one year, though the period can vary and be as long as 18 months. It is often the case that the selected candidate is practising abroad which delays him or her from taking up a consultant post in Ireland for a number of months following selection.
The current arrangements regarding the regulation of medical consultant appointments are under review. It is intended to establish an advisory committee involving medical consultants and senior HSE officials to put in place a more formalised process for making consultant appointments. It is also intended to review consultant appointments in the context of overall workforce planning for the health sector. The HSE is now one organisation and is developing a national focus on workforce planning to examine staffing requirements in their totality across all disciplines to better align resources with service requirements and priorities. In this context, we must be cognisant of the variety of disciplines such as nursing, allied health professions, doctors and other disciplines that provide integrated health services.
The appendix attached to the material circulated to members sets out some statistics on consultant appointments in 2006 when 125 new consultant posts were approved. Members will note that the greatest increase in consultant numbers last year was in psychiatry, which was due in part to the implementation of the Mental Health Act. My colleague, Mr. Martin Rogan, who has responsibility for mental health services, worked closely with me and my colleagues in the consultant appointments unit to deliver the posts.
In summary, the process involved in consultant appointments has four key steps. The first step is the proposal from a hospital network or LHO manager in conjunction with any hospital or agency involved. This often arises from existing policy documents, the service plan or on foot of a local initiative. The second step is consideration of the post by the interim consultant appointments unit in conjunction with officials from relevant HSE directorates in the context of Government policy, the HSE national service plan, published reports and available funding. If considered suitable the post is approved. The selection process for the approved post is a separate process involving the final two steps.
The third step involves the relevant employing authority, which may be a voluntary institution like the Mater Hospital or, in the case of HSE appointments, the Public Appointments Service. The final step is the signing of contracts, which involved the chosen candidate and the relevant employing authority. The contract includes the HSE letter of approval for the post.
The appendix to the circulated material sets out the current level of consultant appointments in Ireland. There are now 2,144 approved permanent consultant posts in the public sector. This number does not include those working solely in the private sector. During 2006, the HSE approved a total of 188 consultant posts, of which 125 were new posts and 63 were replacement posts due to retirements or resignations. The 125 new appointments represent the largest number of additional consultant posts ever approved in one year.
Of the total 188 posts approved, 12 were approved as category 2 posts and 176 as category 1 posts. There are four administrative areas in the HSE. In the Dublin and mid-Leinster region, 38 posts were created while 18 posts were for Dublin north east, 35 for the south and 34 for the west. The distribution of additional posts according to specialty is set out for members in the documentation. The document also sets out the significant increase in consultant posts over the last ten years when compared with the previous decade during which increases were more modest.
I thank Mr. Carey and Mr. Martin for the presentations.
Certain groups made submissions to the committee over recent weeks, including the Cystic Fibrosis Association of Ireland. Its representatives made the point that even though an increased allocation was sought and approved, there were strings attached. It alarmed the committee members that although extra funding had been approved, it could only be taken up in the context of remaining within the limits of the existing staff embargo. If new personnel were to be taken on, existing personnel would have to be moved sideways. We found this difficult to understand. Furthermore, the allocation could only be drawn down if the facility hospital were within budget. We understand there is not much point in allocating extra funding to groups such as the Cystic Fibrosis Association of Ireland if their hands are tied behind their backs by way of embargoes and financial constraints.
I will not deal with the issue regarding the neurosurgeon posts, including for Sligo, as I am sure it will be taken up by Deputy Devins and others. Suffice it to say that we found it difficult to understand that although allocations were made, posts were not filled because the HSE had not advertised them. Will the delegates respond to these issues?
In regard to the presentations, how many of the 331 vacant posts are being filled by locums at present and how many are completely vacant? Neurology and cystic fibrosis were highlighted as specific topics because services pertaining to them are almost non-existent in some parts of the country. The waiting time for neurology services for patients in the south east is approximately four years. There is an urgent need to have a neurologist appointed in the south east and this is why it is being raised as a specific issue.
The same applies to cystic fibrosis services. It is not so much the case that neurological and cystic fibrosis services are the two issues about which we want to talk but that they are the two services that are almost non-existent for a large number of patients. It is pointless talking about an early appointment referral system for neurology in the south east because it just does not happen. I was particularly surprised that the HSE has no role in the appointment of 30% to 40% of the consultants to the hospital service. This amounts to roughly the number of consultants in voluntary hospitals.
The regionalisation of health services across the country is talked about and is supposed to be Government policy. A number of hospitals have been designated as regional hospitals and others as general or local hospitals. As far as I am concerned, regionalisation does not exist. In the past two years, I have visited every part of the country and noted that none of the regional hospitals shows the dramatic improvement required of hospitals of this status. This should be discussed.
I find that the so-called Dublin teaching hospitals are head-hunting consultant staff from the regional and general hospitals. Is there a difficulty when hospitals are taking on consultants? We are often given the impression that there are hundreds of Irish people in America and England anxious to come back to Ireland to work. If so, why are consultants being head-hunted from our own regional hospitals by the major hospitals in Dublin and Cork?
There seems to be a great problem matching resources to consultant numbers. A colleague of mine from college was appointed as a consultant surgeon in a certain hospital but he was given no time in theatre. In other words, he was a consultant surgeon with no access to an operating theatre. The only way he could operate on his patients was to do so during the night. This was the case for a number of months until the surgeon was eventually given a half day during which he could operate.
It is weird that people are employed as consultants but given no access to operating space or the ancillary services they are supposed to be able to use. In the south east, for instance, cardiologists are taken on to conduct angiograms. These are supposed to be carried out in the regional hospital in Waterford, yet this hospital does not have what is known as a CAT laboratory, which is where they should be carried out. All the patients are still travelling to St. Vincent's or St. James's hospitals in Dublin for their angiograms although there are many consultant cardiologists in the south east who are supposed to be doing that job in Waterford. This is clearly a mismatching of resources and it is contributing to the trend whereby patients drift towards the capital. This goes against Government policy. It makes it difficult for patients in Dublin to gain access to routine services because many of the beds are occupied by patients outside the Dublin region who are there to avail of specialised services.
Let me refer to a case in Wexford, which I am sure the consultants will not mind me discussing. A consultant cardiologist was in a locum position for nearly two years at Wexford General Hospital. I was surprised to hear that these posts can be approved after a month. When interviews were being held for the consultant's post, another position arose in Clonmel. The person working in Wexford, who was getting on extremely well with all the local GPs and doing a good job, was told he was getting that job and someone who came back from America for an interview got the job in Wexford. The latter consultant subsequently left the position in Wexford. Thanks be to God this occurred before the year was up. Had he left a year and a day after he was appointed, we would have lost the cardiologist to Wexford because the post would have to have been readvertised. Some locum would probably be placed in the position in the meantime. The consultant who had been in America went back before the year was up and therefore the one in Clonmel was deemed good enough to come back to Wexford. The way we are appointing consultants in the system is therefore ridiculous.
I question the statement that the system is very independent. Over the past ten years colleagues of mine have been able to tell me who would get certain posts in certain hospitals. It therefore seems the system is not as independent as we are led to believe. Will the delegates comment on the fact that people seem to know who will obtain certain posts a long time in advance? Who has the final say in the matter? Do the consultants in the hospitals where the appointments are to be made have a veto over the HSE, or did they have one over Comhairle na nOspidéal when it was in operation?
With regard to the manner in which we are treating non-national doctors, will the delegates state the number of cases they are dealing with that concern non-national doctors, some of whom are taken on in a locum capacity and subsequently told they will be let go? There seems to be a discriminatory policy operating in this regard in the health service.
When the P. J. Walsh case was being discussed we considered in detail the question of who has control and how the system works. Mr. Walsh bled to death in Monaghan General Hospital. At the time, the surgical services for the Cavan-Monaghan hospital group indicated that all serious cases should be referred to Cavan and that none should be operated on in Monaghan. However, there was a protocol that ordained that no major GI surgery was to be carried out in Cavan General Hospital. Why were the three consultants approved on a locum basis to Cavan General Hospital appointed if there was a protocol slapped on them to the effect that they could not operate there, although that hospital was designated as the hospital in the area for major surgery? In some respects, this is how Mr. Walsh lost his life. He could not be operated on in Monaghan and the protocol was such that he could not be operated on in Cavan. Our Lady of Lourdes Hospital said it would not take him.
The system seems to be very dysfunctional, not only in terms of how we match consultants with resources, but also in terms of the limitations we place on consultants. The problems I have outlined are occurring and the questions I have asked need to be answered clearly.
I, too, welcome the delegates and thank them for attending and for their presentations, which I found very informative. This is a topical and important issue. My understanding is that it is down to the local HSE hospital to decide it needs a consultant and it then draws up an application and discusses it with local HSE network managers. It then goes to the HSE consultant appointments unit which then considers and approves it and it then goes for advertising. Is that a correct assumption? Could we get a general overview of the timeframe for each step? It was clearly indicated that once it comes to the consultant appointment unit, it takes between a month and two months to turn it around, which is great, but from the initial step of the local hospital deciding it wants a new post, how long does each step take?
The question of funding was vague. At what stage is that decided and who decides if it will be provided for a post? While we are concerned with the consultant post are the ancillary posts necessary to support the consultant post considered? If so, who decides that and when is it taken into account in the overall procedure? Consultants have appeared before this committee, particularly the rheumatologists, who bemoaned the fact that in some cases they did not have so much as an office even though they had been appointed to a post. Often they badly needed extra therapists and nurse specialists, who had not been provided.
I did not see any reference to the position of time-expired registrars becoming consultants. That is happening around the country. What precisely does that mean, how many are involved and how many will obtain consultant posts by that route?
If I can be parochial, what is the position with the fourth paediatrician in Sligo General Hospital? Both Castlebar and Letterkenny general hospitals, equally distant and equally large hospitals, have four consultant paediatricians while Sligo General Hospital only has three. There is a great inequality in access to community paediatricians. Those who live in certain areas of the county have access to an excellent community paediatric service while those who live in other areas do not have that service as a result of the lack of a fourth paediatrician.
What is the position regarding a nephrologist for Sligo General Hospital? I have a letter from the HSE that states it recognises the need to increase the level of consultant resources for the north west and is pursuing the appointment of additional consultants, one of whom will be a nephrologist based in Sligo.
I thank the delegation for the presentation. I was with Comhairle na nOspidéal before even Mr. Martin so it is a little depressing. At least in Comhairle na nOspidéal we were able to blame the Department of Health and Children for any delays but now we have these supposedly new and improved structures and we still receive complaints about the delays and consultant appointments. Is Mr. Pat McLaughlin's position going to be replaced? Is that relevant to the situation? Is the new consultant appointment unit outside the Act?
It is depressing that we frequently hear that approval has been given for a post and funding has been put in place but there are interminable delays before the post is advertised. Is that totally the fault of the hospitals? I am surprised there is no involvement at all with the voluntary hospitals, although perhaps I misunderstood that.
The facilities for those who are appointed are also a constant source of complaints. Deputy Twomey mentioned surgeons who say they do not have operating time or beds and I have heard from anaesthetists who have been appointed with the same problem and a shortage of theatre nurses. Oncologists have been appointed to find there are no oncology beds for two years. Some streamlining is needed because even if a person is in place, people are not getting the service.
Support teams have been mentioned. Perhaps Mr. Rogan could address the situation in psychiatry. A considerable number of complaints have been made about psychiatry posts. These are now supposed to be in the community but no psychiatric nurses, psychologists or psychotherapists are being appointed to the community to go with them. People are working in totally inadequate circumstances.
The posts that have been approved were mentioned but we have been using these figures for a long time and thought the situation had improved. It is fine to approve the posts but how many have been filled since 2003? I have been involved in boards where we know that it takes time for people to come back from abroad because children must be taken out of school and people must work their notice, they cannot just move. Can anything more be done, however, to reduce the length of time needed to get people into posts? I am very worried about the delay between approval and funding of posts; we hear about that and relax only to find nothing has happened six months later. Last year's neurology posts are like that.
I thank the officials from the Department for attending the committee. We are confused about the embargo. Is there an embargo when it suits the Department and none when it does not? The Cystic Fibrosis Association of Ireland made it clear last week that money is being made available for the appointment of consultants but the embargo is being applied and hospitals are being told they cannot increase the number of staff. If I can be parochial, last Monday at Limerick County Council, a motion came up because money was allocated for an adult cystic fibrosis consultant but the hospital was told that the embargo applied and the person cannot be appointed. Could we see some clarity in this area? We saw a letter sent to Tallaght Hospital allocating money for the recruitment of a cystic fibrosis consultant but it was then made clear that there is an embargo and the hospital could not increase its budget for that appointment. It was clearly stated that someone had to be sacked for the appointment to be made.
Senator Henry and I attended a press conference yesterday held by the Irish Psychiatric Association. The association made clear that the development and implementation of A Vision for Change is being totally frustrated by the application of the embargo. That is what the association says, not just what I say. The appointment of multidisciplinary teams in the community, with psychiatrists, psychotherapists, occupational and family therapists and nurses, was identified as a key factor in A Vision for Change, which was published 12 months ago. Is there an embargo on the appointment of these people? If so, how does the embargo apply to their appointment? Is there no embargo and has the Irish Psychiatric Association got it wrong?
Dr. Kate Ganter chairperson of the Irish College of Psychiatry was present yesterday. She said if there is any commitment to development of the psychiatric service the embargo is foolish. She has stated that there is an embargo. Can the delegation clarify whether there is, or does it apply when it suits the Health Service Executive? Why are these organisations, which have a high profile in the delivery of psychiatric services, saying that the embargo frustrates their development?
I also welcome the delegation and apologise for not being here for the presentation. I was obstructed by traffic. While I intended taking public transport, I must visit somebody in hospital so could not do so. I have listened to some of the debate and have read the presentation.
There is a problem between the appointment of a consultant and the delivery of service. We heard a good example of that this week whereby a paediatric surgeon was awaited. I will not be parochial because the country is waiting for these appointments and we need to consider a health service for the country. However, that position has been vacant for ten years. Who is to blame and why has this not happened? Presumably the Department of Health and Children sanctioned this position yet it has not been filled. Children are suffering as a result. Why is that allowed to continue?
I read here that the processes are changing under a review of the arrangements. Where does responsibility lie? When the Department of Health and Children purchases a service on behalf of the people, we are entitled to receive it. Why do we not get it? Whose fault is that? When does somebody say it is time to intervene because the appointment must be activated? Can the delegation guarantee that will not continue? It is unacceptable. To what extent are the new arrangements subject to negotiations on the consultants contract? Can the delegation guarantee me, as a representative of the people who pay for the service, that this will not continue to happen?
This is only one situation that has been highlighted. I am sure the delegation could document many other similar situations. It is not good enough. According to one of the presentations the Health Service Executive advises that something should happen but that this advice is not always followed. Accountability is our job. I would like the answer to these questions today.
I reiterate Deputy Devins's point about the meaning of a consultant's post. Many people who have presented to this committee have told us that a consultant is a highly trained and skilled individual who should deal with patients but frequently we hear that they have no offices or support structure. They do not need to write letters, they need the support of secretarial staff which is often not provided. The time of many consultants, whom we pay in the public service, is taken up with routine administration. What exactly does a consultant post mean? Does it refer to the individual or does it include the support structures?
I too apologise for not being here for the presentation. I have read the papers. I apologise if I ask questions with which the delegation has already dealt.
Does Professor Drumm's team of advisers have any role in, or input into this process? The delegation has outlined the issues surrounding treatment for cystic fibrosis but it has not answered the question. In such an area, where there is clearly a need, which the Minister has declared a priority, on which a report has been published identifying the needs and staff requirement, and money allocated, why of the 58 required are only 11 in place? Those 11 were already in place but were paid for by charities but now the State pays for them. How is it that when all the elements are in place to deliver a service, there is another review when the Health Service Executive should be telling us that it is three-quarters of the way there or has fulfilled the obligations because the funding is available? The embargo has reared its head and it does not seem logical that everything is done to provide for these services when at the last minute an obstacle is set up to make sure that nothing happens. That is a problem.
Everybody has commented on the delay between appointment and filling the post, especially regarding people coming back from overseas. Is it possible to have a panel system whereby the executive carries out a scoping exercise so that it knows who is there and who wants to come back, which might help the process?
I do not get the sense that there is a strategic approach. It is not a good comprehensive approach to let the Health Service Executive leave it to hospitals to decide when they need new consultants. I may be doing the executive a disservice and I know it is working in particular specialties but leaving it to the individual hospitals to come up with bright ideas does not sound like a bright idea, although they work on the ground and should be listened to.
With regard to the consultants' contract negotiations, we read about it through leaks to the newspapers, the Minister publishes important statements saying she will not do this and a few months later she is silenced by the fact that she cannot deliver on anything she has promised. It now appears from the media that there is a shift such that consultants are being offered the opportunity to have more private practice in public hospitals. That does not fit any sensible approach. Could the delegation say what stage the negotiations have reached? I appreciate this is not an area in which we have any involvement or competence but it involves the public interest and it is the biggest task and challenge facing the Minister. It would be helpful in the public interest if we knew where this was going.
I apologise for attending a little late, I was at another meeting.I will take away the presentations to read. I wish to support my Sligo colleague, Deputy Devins. Will the situation on time-expired registrars be outlined? Concerns have been raised on it, particularly when Irish-trained doctors must leave the country for further training before they can take up a consultant post in Ireland. Do non-EU doctors fall under the same category? Concerns have also been raised about Irish doctors wishing to return to Ireland who are offered a consultant post but that falls short of a full-time post.
A common thread through some of the contributions was the notion there was an embargo on recruitment in the public service. There is not an embargo but an employment ceiling or cap.
(Interruptions).
That is like cancellation versus delay.
Let me explain. The ceiling was set at 96,000 staff in whole-time equivalent terms in December 2002.
That has not happened either.
In December 2006 the Secretary General notified the HSE's chief executive officer of an approved employment ceiling adjustment of 10,450 whole-time equivalent posts. The ceiling has gone from 97,550 to 108,000. That adjustment included staff not previously included or returned in the census when the health boards were in operation, some 3,000 posts; agencies that statutory public authorities took over from religious organisations, some 350 posts; and subsumed agencies into the HSE. It also included 1,060 previous developments without ceiling adjustment, 1,666 approved service development posts — approved for funding in 2005 — and 4,042 development posts to match new services development funding provided in 2006. Funding and additional funding are approved to facilitate an approved business case made by the HSE to the Department.
That has not happened in the case of cystic fibrosis services.
A letter to Tallaght Hospital on the appointment of a cystic fibrosis consultant states—
What year was the letter written?
—the objective also applies to WTE controls even if they were approved as part of a previous year's development. The hospital has the money for the post but it is then told it cannot make the appointment.
I can only speak of what we have done in the Department. In the first nine months of 2006, there was growth of 4,000 in the public health service which suggests new posts are going into place in line with service developments. If approval has been given for a particular project, the funding made available and the technical adjustment to the employment ceiling to cater for the additional posts required to deliver that service, I am unaware—
On that crucial point, why has this not happened? Will the HSE explain that?
We can take the questions through—
No.
I chair the meeting. We will have the responses to the questions asked and we can come back if the questions remain unanswered.
That is passing the buck.
Deputy McManus, I do not pass the buck.
I know the Chairman does not pass the buck. The delegations are passing the buck.
If the question regarding cystic fibrosis services is not answered, I will ask the question again. If any of the responses are not adequate, I will ask them again.
I will ask my colleague Ms Fionnuala Duffy who deals with the National Hospitals Office to address the question.
Ms Fionnuala Duffy
In 2006 the Department allocated €4.7 million to develop cystic fibrosis services with a further €2 million allocated this year. Progress has been made in this regard. We have a working group on cystic fibrosis services that involves the multidisciplinary stakeholders. It worked to ensure the priority would be in line with the overall agreed recommendations in improving the service, which prioritised services at St. Vincent's Hospital.
We agreed 57 posts by hospital across the State which included consultants, nurses, psychologists, pharmacists, etc. Detailed notification was given to each of the network managers on the specific funding available for their areas and the specific posts associated with it. In September 2006, following the discussions we would have as a normal part of our business with human resources and the Department, we agreed to the required ceiling adjustment.
We go through it post by post. Notifications were given to the human resources assistant directors of the four health service areas. These go through hospital by hospital, development by development as to what posts are approved and the associated whole-time equivalent ceiling. Since then several support posts for the service have been put in place.
On the consultant posts, I understand the Cork and Galway ones are at the recruitment stage. St. Vincent's Hospital has an additional respiratory consultant in place. The two posts for Crumlin hospital were advertised in October. The Temple Street Hospital post was recently approved by the HSE and will be advertised soon. The working group decides how it is progressed in a unified way across the system.
In 2007, there will be concrete developments. For example when Mr. Martin went through the 125 new posts approved in 2006, many of those would have been on foot of service development funding that would have been indicated to the system in 2005. One only sees the concrete follow through on the ground the following year. This year will see the respiratory physicians come on board, the balance of 57 posts put in place and a further €2 million funding.
I am not aware of the letter to which the Deputy is referring. If I could have a copy of it, I will follow it up.
The letter states there is support for 4.1 staff and in terms of financial accountability it is critical that the implementation of any new developments be timed in the context of the hospital achieving financial break-even for the year. The objective also applies to WTE controls, even if they were approved as part of a previous year's development.
Ms Duffy
That is a general wording that would go into all notifications.
That is an embargo.
Ms Duffy
No, those four posts tied in with the notification Tallaght hospital would receive that it has approval to increase its ceiling by four posts for that specific service. The HSE will always indicate in any correspondence that in doing so, the hospital must live within the general rules of its overall ceiling and financial budget that applies to the hospital.
It is required to break even. If it hires extra staff, it needs extra funding.
I should like to clarify matters, just to bring the debate into focus. We are not imagining what has happened in the fortnight since people came before the committee to talk about cystic fibrosis. They thanked us for supporting their case over the past year and gave some recognition to the fact that part of their agenda had been moved on. However, they made it clear to the committee that they had presumed they could recruit extra staff in light of the extra allocation until this letter, dated 20 July, emerged from the HSE. They appealed to the committee to try to get this issue resolved. They made the point that on the one hand they now had approval for extra staff, but on the other they were being told they could not recruit. They made it clear to us that in order to recruit extra staff, they would have to sack people — a phrase I am loth to use. They would have to reduce the existing staff complement to take on additionally approved staff. I advised the group that I would raise the issue with HSE officials when they came before the committee today. If there was any doubt in their minds, they would have asked me at that point not to raise the matter.
The second issue is that given the fact that increased funding was made available, a condition was inserted to the effect that it could not be used unless the particular hospital was within budget in all other departments. That is a clear contradiction. Part of the purpose of the HSE coming before the committee this morning was to clarify the situation and we shall have to get this matter sorted out. Is it the case that one part of the HSE or the Department of Health and Children is making approvals while another is not allowing them to take place? That is the kernel of the issue. I have to ask the HSE if there is an embargo.
Ms Duffy
There is not an embargo because we work through any service developments where we receive dedicated funding from the Department — with its HR division — to get a specific ceiling adjustment, post by post. This has been done for all of those developments. We formally notify the position to each of the agencies. For example, Tallaght was notified that its ceiling was adjusted by four, so that it might go ahead and recruit. Somebody has just handed me a letter from the CEO of the hospital, indicating that he can confirm that arrangements are in train "to effect the recruitment of the aforementioned staff".
What does it mean where it says that the objective also applies to WTE control?
Ms Duffy
In general terms every hospital has an overall employment ceiling.
This ceiling specifically has to do with cystic fibrosis.
If the Deputy asks a question, he should at least wait for the answer.
It is stretching credulity to think that letter is saying what Ms Duffy is saying. That letter is not saying what she is saying. It is not saying there are an addition 4.1 posts and to please go ahead and recruit because there is additional money in place and the Minister has said this is a priority.
To be fair, now—
Terms and conditions apply.
Ms Duffy was not aware of the letter before she came in. She has had to respond to the letter as it was put to her.
Absolutely.
Ms Duffy
Could I have a look at the letter?
Some €4.78 million was spent—
We shall give Ms Duffy a chance to read the letter. I propose we suspend for two minutes to allow HSE and Department of Health and Children officials to review the position.
Mr. Martin might just answer the question about the €4.78 million. Who is responsible for that?
We will suspend for two minutes.
Sitting suspended at 10.44 a.m. and resumed at 10.56 a.m.
Ms Duffy
I have had an opportunity to look at the letter dated last July. That letter was superseded by the letter that went out in September. It clearly states at the bottom of the July letter that discussions are taking place with the Department of Health and Children regarding the additional employment ceiling approval for new service developments and that the outcome of these discussions will be made known. These discussions are part of the way we do our business on the new developments. On foot of those discussions, a letter was sent on 18 September to the assistant national director of human resources. This clearly indicated the actual ceiling adjustment for each post. That formal approval subsequently went out to Tallaght, which is reflected in the reply sent by the chief executive officer of Tallaght Hospital, Mr. Michael Lyons, back to Mr. Fletcher of the Cystic Fibrosis Association. The letter indicated that Mr. Lyons was happy to confirm that arrangements were in place to effect the recruitment of the staff. Therefore, the situation has moved on since the position in July.
How much of the €4.78 million was spent in 2006 on cystic fibrosis services?
Ms Duffy
I do not have the exact figure on how much was spent or the breakdown from an individual hospital expenditure budget, but we can get those details if the Deputy wishes.
Does that include infrastructure to back up a consultant post, such as isolation beds?
Ms Duffy
There are two elements to the support and I will deal with the general support, because it came up in urology as well in cystic fibrosis. For staffing support, we do not just look at or approve consultant posts in isolation as there is a recognition that we need to put the appropriate support posts in place. As we went through the cystic fibrosis posts, the approval was for social workers, psychologists, pharmacists, pulmonary function technicians and so on. For a neurology post, we would always approve at least three supports, generally an occupational therapist, a physiotherapist and a clinical nurse specialist. Funding would be provided at least for those support posts in addition to the funding for the actual consultant post. That is how we look at the service.
The approach to the overall infrastructure represents one of the benefits of having the Health Service Executive because we can have a wider and more strategic approach nationally. I took up my job in September and I deal with overall planning and development in the National Hospitals Office. That looks at capital and infrastructural requirements as well as revenue and staffing requirements. We now have an opportunity to dovetail those together. If we take the area of cystic fibrosis as an example, there are infrastructural deficits and isolation facilities are particularly required. In our 2007 capital plan which has been submitted to the Department, we have specifically included requirements for St. Vincent's Hospital and other hospitals in general to address the deficits that exist. These requirements are part of a modernisation programme that seeks funding in the capital programme and which will clearly line up with the service developments to put the appropriate infrastructural facilities in place. That is our dual approach.
I am familiar with developments in supports for cardiology services in Waterford Regional Hospital. Given my role in administering capital funds, I can inform members categorically that the project for a CAT lab for Waterford was part of the capital plan in 2006. The project was formally approved at one of our meetings to discuss capital spending. Formal approval for the development of this facility issued to the south-eastern area and the project is being progressed from a capital perspective.
Ms Duffy mentioned support staff but nothing about non-consultant hospital doctors, NCHDs, attached to a consultant post. Is the recruitment of such staff included in the figures?
Ms Duffy
It is in some cases. In the case of neurology and cystic fibrosis services, however, most of the funding went towards consultant and allied health professional supports rather than junior doctor supports.
In many cases, it is not feasible to appoint a consultant without also making provision for medical support staff.
Ms Duffy
All such appointments are considered case by case.
I thank Ms Duffy for this clarification.
Ms Duffy
We have an opportunity to take a more holistic approach. Previously, a separate body, Comhairle, focused specifically on consultant posts while the former health boards looked after the provision of support staff. This process is now integrated under the Health Service Executive. In being able to consider needs in terms of consultants, supports and infrastructure in tandem, we will be able to plan in a much more joined-up way.
That is good.
Ms Duffy said capital funding is approved for a CAT lab at Waterford Regional Hospital. How soon will this facility be available for use? Are further discussions and planning required?
Ms Duffy
This project was discussed and approved for implementation under the capital programme. I can follow up with the network manager as to the status of the project.
I would be grateful if Ms Duffy could pass that information to me.
How long is it since approval for this project was given?
Ms Duffy
It was given sometime between July and September 2006, at one of our monthly meetings. I do not recall the specific month but I can find this out from the notes of the meetings in that period.
Was the decision made several months ago?
Ms Duffy
It was taken at one of our monthly meetings between July and September.
There seem to be significant delays in implementing this project.
It was part of a plan that was devised several years ago.
Ms Duffy
I cannot speak for what happened in previous years before I was in my current role. If members wish, I can get them a copy of the approval letter that issued last year in respect of the CAT lab for Waterford Regional Hospital.
Ms Duffy did not address the issues raised by Senator Henry and me in regard to multidisciplinary community-based psychiatric teams and the allegations of the Irish College of Psychiatrists and the Irish Psychiatric Association that the recruitment embargo is preventing any development in mental health services.
My colleague, Mr. Martin Rogan, has responsibility for mental health services.
Deputy Neville mentioned that yesterday was the first anniversary of the launch of A Vision for Change, which outlined an ambitious programme for the delivery of mental health services. The modern mental health service is largely based around the community-based mental health team. Within this model, the role of the team is not unlike that of the family in the Constitution. In 2006, as part of the growth of our services for the purposes of improving capacity and reach and fulfilling requirements under the Mental Health Act 2001, 18 new multidisciplinary teams were established in the area of adult psychiatry. Unfortunately, however, many of our services nationally include significant numbers of staff who are still working in an institutional setting. The new approach presents an opportunity to redeploy some of these staff.
In devising a new approach to mental health provision, we began by considering current population data, based on the 2002 census and since updated with 2006 information. Teams were allocated on the basis of catchment area population and the profile of that population, with deprived communities having an additional weighting. All services were ranked in terms of community served, current provision and ratio. We found, for example, that one consultant psychiatrist might be catering for a population of 19,000 in one area and up to 40,000 in another. We allocated new teams on the basis of the 18 areas with the least satisfactory provision. The model we devised reflects population growth, urbanisation and so on.
Progress is being made in putting these teams in place and in most cases, a locum is already in situ. Where local services were able to adopt a locum, that was done. Otherwise, we work with our colleagues in the Public Appointments Service to appoint locums. By the end of this month, competitions for permanent posts will commence.
Several of the posts are developed in association with our colleagues in the Dublin area teaching hospitals, usually on a seven-four consultant session basis, that is, four to the hospital or inpatient setting and seven to the community. In all new development funding projects in mental health for 2006, a business case was prepared locally in conjunction with local health management teams to determine the construct of the team and whether, for example, there should be an emphasis on psychology, social work, occupational therapy or nursing.
In 2006, 383 new posts were created in the area of mental health. In our allocation for this year, we have an additional 254 posts across all disciplines. In terms of team members, it is a question of redeploying where there is an opportunity to do so and recruiting additional staff when necessary. An additional 1,800 posts are envisaged under the seven-year lifetime of A Vision for Change. The vast bulk of these will be allocated to community-based teams.
Did Mr. Rogan refer to 24 posts? It was brought to our attention yesterday that 660 additional staff are needed. At this rate, it will take 25 years to get the teams in place.
Mr. Rogan
We must factor in the question of the availability of staff. Some of our allocation in the past two years was put towards training. This will help to extend capacity in psychology, psychiatric nursing and other therapies. It is vital that candidates with the appropriate skills are available both in Ireland and internationally to take the places on these teams. We are keen that the team model should grow in a coherent manner. Simply having a group of individuals from different disciplines does not constitute a team. It is important to build and grow a team carefully and that it should have a clear purpose. In 2006, the year in which A Vision for Change was introduced, €26 million in funding was allocated and 383 whole-time equivalent posts were created. This year, the €25 million in funding will be used to allocate 250 posts.
I am conscious that some staff working in the mental health arena have a partial time commitment where a post may be shared among several individuals. This complicates the picture. One of the tasks in our roll-out of A Vision for Change is to look at the distribution of all our staff. Some areas have a significant cluster of nursing staff but others may not have equal access. It is part of the HSE's function to adopt a unified approach so there is equity of access throughout the State. We must extend our capacity.
Without being unkind, it looks as though progress will be very slow. The €25 million for the service this year is the same allocation as last year. When one takes account of inflation at 5%, this means there is a diminution in funding.
Mr. Rogan
The allocation is determined at a different level. Once it has made its way to the HSE, we work with service providers to ensure an equitable distribution of that resource. We are concerned not only with ensuring the teams are available but also that they have the resources and materials to do their work effectively.
The Irish Psychiatric Association claims the so-called meagre increase in funding for mental health in 2007 brings provision in this area as a percentage of the total health budget down to below 6%. Is this correct?
Mr. Rogan
When A Vision for Change was drafted, mental health funding as a proportion of health spending was 6.7%. A Vision for Change pitches that towards 8.2% over the lifetime of the strategy.
Will it be below 6% this year?
Many of our questions have not been answered. Can we deal with those before allowing members to put forward supplementary questions?
We are trying to get a broad understanding of the issues and using this opportunity to cover as many aspects as possible.
I understand that but it is quite frustrating.
Is Mr. Rogan saying that a lack of personnel both nationally and internationally is a limiting factor in the implementation of A Vision for Change?
Mr. Rogan
We are ensuring there is a supply chain of new professionals available to us as we grow towards a full implementation of that strategy. International recruitment happens routinely in the mental health service. We have many staff from South Africa, India, the Philippines and elsewhere. Our intention is to ensure we have balanced growth across all disciplines. In the past, some disciplines did not have the capacity to meet our full requirements for multidisciplinary teams. Additional supports are now in place to ensure progress.
Mr. Rogan is indicating the HSE has a serious problem in this regard.
I want to ensure questions that have already been put are answered. Supplementary questions may be put later. There is no need for Deputy Neville to shake his head; all his questions will be answered. I ask Mr. Martin to respond to members' questions.
There was slight confusion earlier in regard to the role of voluntary hospitals. The HSE has no role in respect of private hospitals. However, while voluntary hospitals such as the Mater Hospital, St. Vincent's Hospital, St. James's Hospital, Beaumont Hospital or their equivalents are not owned by the HSE they are funded by it. Although they are so funded, they have independent boards and carry out their own recruitment for consultants and all other positions. Each hospital has its own independent recruitment system for each position.
In the case of the HSE hospitals and those providing mental health services, senior level or consultant posts are recruited by the Public Appointments Service on behalf of the HSE. Deputy Twomey cited an example of a consultant who was a locum in Wexford. While locum, or temporary, appointments are made by the local service, permanent appointments are made through the Public Appointments Service. The competitions are run by the Public Appointments Service, which carries out recruitment, interviews and the selection of the person who gets the post. When several posts are available, as in the instance provided by the Deputy, it establishes a panel. Hence, it is a matter for the Public Appointments Service, rather than the HSE, to recommend the candidate.
I seek clarification. Mr. Martin mentioned the operation of a separate recruitment process by the voluntary hospitals.
Each hospital has its own process.
Does this refer to the recruitment process?
Yes.
However, prior to that, is the approval and funding of a post the same for voluntary and HSE hospitals?
Yes.
This only refers to the recruitment process.
Yes, recruitment is different.
Very well.
I agree with Deputy Twomey regarding the appointment of consultants without having all the facilities in place. While this is not our intention, it is often a chicken and egg situation. Sometimes, the facilities will not arrive until the consultant is in place to drive matters forward. As the Deputy noted, this can happen occasionally. However, no one welcomes it.
In this case, a consultant was appointed to a position at a regional hospital. While members have discussed logistical problems, such as lacking secretaries or offices, it is strange that a consultant could walk into a position without even having dedicated operating time.
I am surprised to hear it. Perhaps the Deputy and I can have a word about the case in question later and I will pursue it.
I refer to Deputy McManus's question as to whether the HSE has a strategic approach to consultant appointments or to general health service appointments. Now that the HSE is a single organisation, it is being developed. This is the reason people such as Mr. Rogan and Ms Duffy have been appointed with significant roles regarding planning mental health or hospital services. This approach is also being integrated with general human resources and workforce planning as we wish to adopt an overall approach to health services recruitment and the types of posts needed. As this will not apply simply to consultant posts, consultant appointments will constitute an element of overall workforce planning.
We are moving towards this approach to provide top-down, or national advice and direction to the system, while not stymying local initiative at the same time. A balance must be achieved between nationally based policies from various departmental—
When will the plan be published?
It is being worked on at present.
I know that.
Within the next few months.
I thank Mr. Martin. Within the next few months.
Yes.
I will respond to some other questions. Mr. Pat McLoughlin was replaced by Mr. John O'Brien as director of the National Hospitals Office approximately one year ago. I refer to the issue of time-expired registrars. Registrars constitute one grade and those who want to be a consultant must compete for a consultant post. Sometimes lapses can occur between getting a post. Furthermore, not everyone gets a post.
That is not my information. My information is that people held senior registrar posts for a long time and had an automatic right to become consultants in the hospitals in question. Is that correct?
One does not have an automatic right to become a consultant.
Is Mr. Martin absolutely sure?
Yes. Not if one is a registrar.
After seven years, non-nationals have a right to remain in Ireland.
My information is if they remained in a hospital for longer than they should and that, de facto,—
The Deputy is correct.
—they had an automatic right to become consultants in such hospitals. Is that correct?
Not if they were registrars. The locum consultants—
What about senior registrars?
No, locums are—
Are there other circumstances in which they are—
Mr. Martin should take the case of locum consultants.
There is an issue arising from the Protection of Employees (Fixed-Term Work) Act that applies to nurses, paramedic supporters or any employee nationwide. Potentially, people who are employed for three or more years in a temporary capacity may acquire a contract of indefinite duration. However this issue is general and is not confined to the health services.
I apologise for mentioning registrars as the issue may have pertained to locum consultants. However, my information is that this has happened. People who were appointed in a locum capacity have been appointed in a permanent capacity without being obliged to go through open competition.
A small number of people have been appointed following court cases in which the courts awarded them contracts of indefinite duration at whatever position they held.
Effectively, this means they are consultants in the relevant hospital.
A few such instances have arisen recently and I am unsure how it will pan out over time. However, it is a significant issue to be addressed.
If the courts have adjudicated on the matter it sounds as though it is true.
Yes.
Hence Deputy Devins's point is correct.
Substantially.
Does Mr. Martin know how many people are involved?
No.
This is a long-standing problem in which the HSE has been caught out by the courts. People have been given locum consultancy positions that are not being advertised in the proper manner. Subsequently, if a person remains long enough, he or she can claim to keep the position on a full-time basis. Is this not what happens?
That seems to be beginning to happen.
They are left there for too long. We now run the risk of doing the opposite, that is, we will begin to throw such people out of the posts in question before their time expires, thus creating an even greater mess. Is that not the case?
That is a fair viewpoint. However, this issue applies across the entire public sector.
How can the HSE avoid it?
The legislation is in force.
Does this not pertain to giving more attention to the contract? When a contract has expired, someone should be required to—
Yes, this calls for careful management of temporary contracts.
Given that this problem has been highlighted, is Mr. Martin satisfied this is happening?
As the issue has been identified, I am certain the HSE's human resources directorate will address it. However, this is not my particular area of expertise.
I refer to the delay before posts are advertised. Posts are sanctioned by the HSE and it is then a matter for the individual hospital, be it voluntary, HSE or part of the mental health service, to get the show on the road and to advertise the post. However, this can take some time. Many steps are involved, including setting up a recruitment panel and an interview board, as well as the actual selection process. As Senator Henry noted, many candidates, particularly for consultant posts, live abroad and consequently it takes six months for them to return to take up their duties. Usually, this stretches out the process to a year.
Do such posts go before Professor Drumm's team of advisers, or to any individual members of the team?
No.
Not at any stage?
No.
Never?
No.
To clarify, is this response an answer to my question as to why this has taken ten years?
No, it is not. However, I will now answer that question.
Very well. I wish to know how to ensure it will not happen again or will not be allowed to continue.
This was a unique situation, in which there was a significant difference of opinion between the individual children's hospitals as to how paediatric surgery services should be organised in Ireland.
May I pursue this issue? A stand-off between hospitals is not good enough.
I agree.
Although the State is paying for a service, sick children are left without it. How can one ensure this will not continue? There is no method to so do. How can one guarantee this will not continue?
Ms Duffy
I wish to comment on this matter as I have come to this area recently. As the Deputy noted, there has been a stand-off and an inability to secure consensus and agreement. We have moved on from that position, through working with the three hospitals and through the council of children's hospitals that facilitates some collaborative work. We made some progress recently in respect of the establishment of a joint department of surgery, encompassing the three hospitals concerned. In that context, we are trying to reach agreement on the structure of the paediatric surgeon post.
When does Ms Duffy envisage the appointment being made?
Ms Duffy
As soon as we get the sign-off in writing and the contract typed.
I will watch that space with interest.
Ms Duffy
We are nearer to that point than we have been in the past ten years.
I would hope so.
Who has had a veto over a paediatric surgeon post in our health services for the past ten years? Someone ran the health service during that time, but our guests are implying that consultants in the two hospitals blocked the appointment of a consultant paediatric surgeon in the children's hospital.
It was not the consultants necessarily, but the hospitals. As they are voluntary and funded by the HSE, previously they were funded directly by the Department of Health and Children rather than owned by the HSE, they have greater discretion than Cork University Hospital, Wexford General Hospital, etc.
Do they have greater discretion to the point of blocking the appointment of a paediatric surgeon for a decade?
The post was filled by a series of people on a temporary basis.
It was not an ideal situation.
I agree with the Deputy.
I hope that the hospital will let the right sort of person take the post.
Ms Duffy would like to make a number of points on neurology services.
Ms Duffy
The gap in neurology services in the south east was referred to. We have provided €400,000 for the development of neurology services in the south east and a letter of approval for the consultant post was issued by the HSE in December 2006. The Deputy should see the post advertised soon.
Was the post approved then?
Ms Duffy
The letter of approval to advertise for and recruit the consultant neurologist was issued at that time.
What will the €400,000 pay for besides the consultant?
Ms Duffy
It provides for start-up funding for a post and part-year funding to start with an occupational therapist, physiotherapist and clinical nurse specialist. This is the seed funding we invest normally. Like neurology, cystic, renal and other services, we take a multi-annual approach. While we invested €3 million in neurophysiology services across the system in 2006, the Department has given us a further €2 million to further matters in 2007, which gives us scope to examine the further development and expansion of some of the existing services.
The money for neurology services in the south east was approved in October 2005. The letter of determination was received in November and, a year later, Ms Duffy tells us that the position has been approved and that the HSE will set up the office and the recruitment process. This is a slow process. It will be December 2007 by the time the consultant neurologist takes up the position in Waterford General Hospital.
Ms Duffy
This is the type of situation we are trying to change, improve and streamline and in respect of which the HSE is trying a different approach. We received the funding in December 2006. We are required to produce a service plan, which must be submitted to the Department for formal approval and an endorsement of our intention to use the funding to improve services.
A great deal of work must be done to get formal approval post by post and to get applications submitted. It is often the case that applications received do not address the issues referred to, such as an assurance about theatre capacity and outpatient slots. These factors must be worked through before a post can be put in place. It is inevitable that a development will take time to get off the ground during the first year. Only in subsequent years does the process speed up and the service on the ground improve.
I was going to mention the nephrologist post in Sligo, which relates to previous points on bottom-up, top-down and strategic approaches. We have a strategic approach to renal services. As Deputy Devins is aware, there was a commitment to review renal services nationally. The review has been undertaken and a national renal strategy document produced. The working group was chaired by Dr. Liam Plant, a nephrologist from Cork University Hospital. The report is before the population health directorate so that we can start to implement it in 2007 with the development funding provided by the Department which amounts to €4 million nationally. Included in the 2007 priorities is the nephrologist post in Sligo. This year, the Deputy will see progress in that respect, which will be set out clearly in our approach to the developments in the 2007 service plan.
Regarding following through on development funding in subsequent years, a section in the service plan concerning the National Hospitals Office indicates that we will continue to track all developments to which initial funding was given in 2006, such as cystic, neurology and renal services. We will not focus on 2007 funding only. Rather, we will continue to track the previous year's development to ensure the intention is followed through. This is part of the role of the National Hospitals Office in terms of planning and follow through.
What about the paediatrician post?
Ms Duffy
I am not familiar with the fourth post. I must check because I am not sure as to whether an application has been received.
I will speak with Ms Duffy after the meeting.
I am trying to recall the questions we have not covered.
There was another question on the key issue of funding. The procedure of hospital applications and so on was outlined, but who approves the funding for each post and where does it fit in the timescale of the development?
The individual directorate, PCC or NHO approves it. If the post is hospital-based, such as in Sligo, it would be dealt with by the National Hospitals Office headquarters, namely, Ms Duffy and her colleagues.
They approve the funding.
They find the funding.
Ms Duffy
To illustrate with an example, if we take—
I am sorry. Excuse me for laughing.
Ms Duffy
Taking a particular service's funding, such as the €4.7 million for cystic fibrosis in 2006, we get it in a block. Through working groups, we decide on where the funding will end up. Working to a schedule, we break it up agency by agency and determine how much each agency will get. For example, Cork University Hospital was allocated €721,000 of the €4.7 million.
When we have broken down the details, we give instructions to our finance unit to allocate the additional funding to the agency and we write a letter to the network manager, stating that under a specific funding code, the service will get an amount for A, B, C and D. We follow through with the whole-time equivalent approval. This is the same process through which a letter was sent to Tallaght Hospital last July.
Mr. Martin is missing the elephant in the room.
Which particular elephant might that be?
The negotiations on the consultants' contract.
They are ongoing.
The elephant has left the room.
Mr. Carey is still on record.
I will withdraw that remark immediately.
I understand the chairman of the talks will issue a statement or paper on the position this week.
Will there be progress?
I am not sure what he will say.
Can Mr. Martin confirm that the proposal is to allow consultants more private practice in public hospitals?
The Deputy may be relying on Professor Drumm's comments on radio last weekend, but that is not what he stated. Consultants in public hospitals have private practice therein as part of their contracts.
An article in one of the Sunday newspapers, perhaps the Sunday Business Post, itemised the proposal in some detail.
I did not read that article.
Mr. Martin will not tell us anything.
I would tell the committee anything I know.
Does Mr. Martin know nothing?
On this specific point. The approach of the HSE is to have consultants working exclusively on publicly-funded hospital sites as distinct from working in two places.
How much progress has been made?
We will determine that when Mr. Connaughton makes his assessment of the situation. It is fair to say there will be a difference of opinion between the parties.
When does Mr. Martin expect the statement to be published?
This week.
Is Mr. Martin saying that the HSE has dropped its commitment to public-only contracts and is still intent on abolishing category 2 contracts?
I am not saying that. We, that is the Departments of Finance and Health and Children and the HSE, will consider the issues in the context of Mr. Connaughton's assessment.
It has taken a long time thus far. Has it not been three years?
A number of efforts have been made.
The controversy over the introduction of the clinical indemnity scheme caused delays in getting the negotiations under way. It is not a question of the management side dropping the notion of a public hospital contract. A variety of options are being discussed, even including private practice in public hospital sites. I have not seen the newspaper article in question.
That would mean simply following through on the existing category 1 contracts.
That is so but we may be considering salaried consultants who have a total commitment to the public hospital.
The confusion arises with regard to the co-location project because category one contracts would allow consultants to work in new private hospitals on the grounds of public hospitals, whereas a public-only contract would not allow them to work in a private hospital. That has long been the Minister's stated commitment but it is not clear whether the HSE has made a similar commitment in its negotiations on the consultants' contracts, even though it is radically altering the way Irish health care services operate. Consultants have a significant role to play but the HSE is not making it clear whether category 1 or public-only contracts are the way forward.
Specific provision for co-located facilities is one of the issues we would like to have addressed in the context of the negotiations with consultants.
We are still rushing forward with co-location and the Minister is suggesting that the contracts will be signed by April, yet the contract negotiations with consultants appear to be dead in the water. It is amazing that large amounts of public assets are being transferred to private developers in the absence of consultant contracts. We are responsible for public assets rather than the commitments of private developers. That is a dangerous prospect for any Minister.
The policy objective behind decanting private beds in public hospitals to private facilities is to free up beds for public patients.
As we all know, the reality is that everyone is a public patient. Private beds may be decanted but private patients will remain in public hospitals. The proposal is a myth. I appreciate it is a political decision but it is a bad decision and is causing mayhem. What happens if this policy is maintained and negotiations run into the ground? How can it proceed? It seems that stalemate has been reached. Is there a plan B?
I would be happy for Mr. Carey to answer that question.
That is from the person who is leading the management negotiating team. We should await the assessment of the independent chair because we are still in a negotiating forum with the IHCA and the IMO. With respect, it is inappropriate to discuss issues pertaining to the negotiations.
Next week's assessment will solely concern the progress of the negotiations.
The point I am making is that the Minister says she is intent on signing contracts for the transfer of land to private developers and the construction of private hospitals. We do not yet know whether the consultants who are currently employed in public hospitals will be allowed to work in private hospitals. This is a chicken and egg situation, in that public assets will be transferred without clarity regarding who will be working in public and private hospitals. The idea that contracts for hospitals would be signed before the completion of negotiations on consultants' contracts seems unbelievably stupid.
I can do no more than note the Deputy's comments.
We will know the position of the negotiations by next week and the political head of the Department will be here within the next two weeks to answer the Deputy's question. It is not fair to put the question to the officials before us today.
I ask that we be given a copy of the assessment as soon as it is published.
That will be organised and we can raise the issue with the Minister for Health and Children and Professor Drumm when we meet them in two weeks.
The question I raised on the appointment of consultants to regional hospitals was not addressed. Having visited most or all of the regional hospitals in the country, it is obvious to me that a deficit exists. Even though it was Government policy and part of the Hanly report to beef up regional hospitals, services are lacking at regional level.
The intention was to develop the regional hospitals by investing resources in them and that is happening. I can provide the Deputy with a list of the consultant posts sanctioned over the past year, which demonstrates significant developments in various regional hospitals.
According to my own experience, Waterford Regional Hospital suffers consultant shortages in the areas of ear, nose and throat, orthopaedics and neurology. We are not demanding neurosurgery or complex tertiary services but simply want standard specialised secondary care services. The deficit in the south east remains significant.
Those services are located in Waterford for the region.
However, the waiting times are significant, which indicates a continued lack of real commitment to regional services. With regard to the CAT laboratory, which was only approved one month ago, regionalisation was supposed to take place over the past three years. I do not think a serious commitment is being made to regional hospitals.
I would not agree with the Deputy. As a unified organisation, the HSE is keen to develop services throughout the country on a regional basis, consistent with minimum viable size. That is the clear commitment by the HSE. However, time is required to bring massive change.
I am not referring to massive change but to building up regional hospitals, which has been policy for the past decade.
What happened in Cavan? Why were three locum consultants appointed with restrictions when they are supposed to be responsible for regional services.
I do not know. Perhaps Ms Duffy has more information on the matter.
Ms Duffy
I do not but I could investigate it.
My question was based on the Teamwork report into the death of P.J. Walsh.
Ms Duffy and I are on the steering group which was established as a result of the Teamwork report in order to improve services throughout the north east and to develop a new regional hospital.
That is a case of dealing with the services which are currently available rather than planning for the next 15 years. The appointment of the three consultants should be investigated.
We have had two good hours of open and frank discussions and we look forward to meeting the Minister and Professor Drumm. I thank the witnesses for their responses.
The joint committee adjourned at 11.40 a.m. until Thursday, 1 February 2007.