Last week I published the Report of the National Task Force on Medical Staffing. It completes the package of reforms set out in the health service reform programme announced in June. Its implementation is vital to achieving the kinds of improvements in health care that we want and that the public deserves.
My starting point has always been to do what is best for patients, and this report is about patients. It aims to ensure that consultants are more involved in patient care by taking a hands-on role in the provision of services, that junior doctors are better trained, awake and alert when they see patients and that patients will be treated in hospitals that are fully equipped and staffed to cope with their condition, whether serious or not.
I established the National Task Force on Medical Staffing in February 2002 to devise an implementation plan for reducing average working hours of NCHDs in line with the European Working Time Directive, to assess the implications of moving to a consultant provided service and to address the medical education and training needs of doctors in this context. At present, most front line medical care in our hospitals is delivered by junior doctors, NCHDs, most of whom work excessively long hours. Patients have limited access to consultant care. NCHDs will soon be required by law to work fewer hours.
The task force set out to answer a key question. How do we safely provide hospital services, 24 hours a day, seven days a week, as the working hours of our junior doctors reduce in line with EU law? The task force brought together hospital consultants, NCHDs, doctors from general practice and public health, the nursing and midwifery and the health and social care professions, health educators, the medical unions, managers and representatives of the public interest.
During its work, the task force took particular account of two previous reports: the report of the Medical Manpower Forum and a report chaired by David Hanly on the working hours of non-consultant hospital doctors. Both were completed in 2001 and they highlight a consensus regarding the need for more consultants, new work patterns and fewer junior doctors working shorter hours. The reports pointed to the need to re-examine how and where we will provide acute hospital services in the future.
A priority for the task force was to ensure that, as it studied the measures needed to develop a modern, efficient and patient centred hospital service, sight was not lost of the value of keeping services at the heart of local communities. In order to meet the requirements of the European Working Time Directive and to deliver a better service to patients, the task force has made certain recommendations. It has set out a series of immediate measures to reduce the working hours of junior doctors to 58 hours per week by 1 August 2004. It has concluded that the only way to address reductions in the working hours of junior doctors while providing high quality patient care into the future is to introduce a consultant provided service. It has argued that a full range of acute hospital services should be available within each region, so that patients should not have to travel beyond it other than for services that are best provided at supra-regional or national level. It has recommended investment in local hospitals to provide more services for patients, including elective medical and surgical procedures, out-patient services, pre-natal and post-natal maternity services and better access to diagnostic facilities.
The report also proposed retaining and developing the minor injury and illness services in local hospitals, which currently account for 70% of patients attending accident and emergency departments, and set out a series of principles for the future organisation of hospital services nationally. It outlined measures to reduce junior doctors' hours to 48 hours a week by 2009, improve training and introduce a consultant provided service over a ten year timeframe.
In response to the task force report, I have set out a programme of action which will enable patients to be treated by a larger number of senior doctors working within a reorganised hospital system. Patient care will be the responsibility of teams of consultants, supported by junior doctors working safer hours in an improved training system. Non-consultant or junior hospital doctors have played a key role in service delivery in the hospital system for many years. More than 4,000 junior doctors currently deliver front line services in more than 40 public acute hospitals and numerous other health agencies. Junior doctors work an average of 75 hours a week on-site, while many work considerably longer, often for extended periods without rest.
The task force has proposed a series of important national measures aimed at reducing the average working hours of non-consultant hospital doctors. The immediate target is a reduction to 58 hours a week by 1 August 2004. These measures include replacement of the present system of tiered on-call, increased use of cross-cover arrangements, the introduction of new working and training patterns for non-consultant hospital doctors and a set of measures aimed at reducing the workload of non-consultant hospital doctors in areas in which other staff are better placed to deliver a quality service.
There is one measure which the task force rightly rejected, namely, the recruitment of extra junior doctors. The discussion document, Medical Manpower in Acute Hospitals, also known as the Tierney report, dealt with this issue ten years ago. It pointed out that the growth in junior doctor numbers, which had resulted in two junior hospital doctors for each consultant in the public sector, had adverse implications for patient care, the efficient operation of hospital services and the future career prospects of doctors in training. Since then junior doctor numbers have increased substantially. We have more than enough junior doctors and now need more consultants.
The Tierney report is an important document given that it suggested ten years ago that we should have up to 1,500 senior consultants by 2003. We now have more than 1,730 senior consultants, in other words, we exceeded the Tierney recommendations. I say this to illustrate that what is proposed in the Hanly report is achievable over a ten year timeframe. I have heard comments to the effect that the proposals will not be achieved. Tierney's estimate of the required number of senior consultants has been exceeded.
There will be other issues surrounding the Tierney report which were not advanced at the time, including the reorganisation of acute hospital services. However, there was also the issue that the appointment of a new hospital consultant required the appointment of a new team, which resulted in the number of junior doctors increasing from more than 2,000 to more than 4,000. Hanly proposes a more complete package involving all the various players, disciplines and professions. It also had to consider another imperative, namely, the working time directive which imposed a discipline on the exercise that was perhaps missing from previous exercises.
Our current ratio of junior doctors to consultants limits the extent to which consultants can deal directly with patients. In order to achieve a consultant provided service, we require a substantial increase in the total number of consultants and a corresponding reduction in the number of non-consultant hospital doctors. Significant change will be needed in the current consultant contract. Consultants will be expected to work in teams, sharing responsibility for patients with their consultant colleagues. Agreement will be required to enable consultants to participate, as required, in the provision of on-site cover in the hospital over the 24 hour period and there must be clarity regarding the proportion of a consultant's time appropriately spent on clinical and training commitments. These requirements are essential to the development of a genuinely consultant provided service. There can be no question of moving to this system in the absence of a substantially changed contract.
Reform of our medical education and training system is a vital component of the new service model. Because medical education and training for NCHDs is intertwined with service provision in our hospitals, we will need major changes in how we deliver and organise medical education and training in a shorter working week. Genuine training posts for all NCHDs are integral to a consultant provided service. I look forward to speedy implementation of the task force's wide-ranging recommendations in this area, which include integrating training functions currently scattered throughout numerous agencies; top quality, safeguarded training, oriented to a new model of service delivery; a flexible training strategy; and measures to address the concerns of non-EU doctors in training. The medical education and training group of the task force is currently working on a number of outstanding issues and I expect it to provide me with a final report in the new year.
Earlier I emphasised the challenge facing the task force regarding acute hospital services. How do we safely provide hospital services, 24 hours a day, seven days a week, as the working hours of our junior doctors reduce in line with EU law? The task force has responded by setting out a new way of organising hospital services. Its proposals mean that no hospitals will close. Instead of downgrading hospitals it proposes to bring services closer to patients while ensuring those services are both safe and sustainable.
This was pointed out by a number of consultants who were part of the Hanly group. One can cite the example of a speciality such as rheumatology. There is only one rheumatologist in the entire mid-west region. Until quite recently, there were no rheumatologists in the west. Also, up to quite recently there was not even a neo-natalogist in the Western Health Board region. Everyone focuses on trauma and acute emergency treatment – this is where the debate immediately leads. There is a wide range of specialities and services for which people in the regions have to travel to Dublin or other areas. The Hanly report says this need not be the case. With the exception of tertiary treatment, such as cardiac surgery, liver transplantation and so on – obviously they will take place in national centres – the vast array of other specialities can be delivered in the regions. There is no reason why we cannot give additional services to local hospitals in terms of routine elective surgery. For example, there is no reason local hospitals cannot do routine ENT surgery, or offer a much greater range of diagnostic facilities, pre and ante-natal services and so on. The Hanly report says local hospitals might not do everything they allegedly do. There is a large question mark over what people think happens in emergency services and what actually happens. Hanly makes the point that local hospitals can provide services which they currently do not provide. The type of services provided by hospitals, in the appropriate setting and in a safe context, is at the core of the debate.
A key part of any reform of our hospital services is clearly a reorganisation of emergency care. International evidence, cited by Hanly, is clear on this. Patients do better in hospitals that have the required numbers of specialist staff, are able to provide suitable medical cover 24 hours a day, seven days a week and have high volumes of activity and access to appropriate diagnostic and treatment facilities. At the heart of our reform programme, however, is the recognition that while we need to concentrate emergency care in our major hospitals, reorganisation of acute hospital services offers the potential for a wide range of safe, effective, high quality care to be offered in our smaller hospitals.
Those hospitals identified by the task force as local hospitals are ideally placed for that role. The core of their services will include elective medical and surgical procedures, day surgery, minor injury and illness units, high quality diagnostic services, outpatient clinics, pre and post-natal maternity services, intermediate care and rehabilitation and convalescence beds. These services will be provided by a group of health professionals including consultants, NCHDs, general practitioners, specialist and staff nurses, radiographers, physiotherapists, occupational therapists and other health professionals. In summary, I expect them to provide an increasing volume of elective procedures and the kind of multi-specialist day and outpatient care that is currently performed in the larger hospitals. Far from downgrading, these hospitals should be developed further to give people local access to a wider range of hospital services than they enjoy at present. Managing the changes required will be challenging and I will not understate the magnitude of the task ahead.
I wish to proceed with the implementation of the process. In order to reduce average working hours of non-consultant hospital doctors to 58 hours next August, we need immediate engagement between management and the Irish Medical Organisation. I have asked the Labour Relations Commission to convene a meeting between both sides to agree quickly a process for negotiating the changes required. Closely linked to this process will be the negotiations on a new contract for hospital consultants. At my request, the Health Services Employers Agency has contacted the medical organisations to arrange an early meeting to discuss the format and terms of reference for the negotiation of a new contract.
I also want to implement the changes proposed by the task force in the east coast and mid-western regions. To do this there will be a project group in both areas which will include management and health professionals from the hospitals involved. These groups will engage in a detailed planning exercise, identifying how best to reconfigure services and staffing at local level. With regard to future organisation of acute hospital services, I have asked David Hanly to chair a small group to prepare a national plan in line with the principles set out by the task force. His group will liaise closely with my Department and, on its establishment, with the national hospitals office. The project group which addressed medical education and training issues is now in the process of preparing its final report.
The Hanly group engaged in an exhaustive process of consultation prior to writing the report. It met with approximately 600 people in both pilot areas, including consultants, junior doctors, nursing staff and other health care professionals. There were about 300 meetings. Whatever one's views of the exercise, it was detailed. It looked at the issue from a green field perspective in the sense of examining the best way to organise health services in the future for a population of 350,000. The question of what was the best and safest service for the patient is what ultimately motivated the conclusions of the Hanly group and it is the reason the Government has accepted and endorsed the group's conclusions and recommendations.