John Gilroy (Labour)

I welcome the Minister of State. I am pleased to have the opportunity to speak on this Bill. I have high hopes for a constructive debate without any descent into a political row or any use of the Bill as a platform from which to hurl party political missiles. I say this without political bias.

I am surprised that anyone should be surprised at the latest crisis in the health system. Two weeks ago in the House we discussed the funding shortage which arose with regard to the nursing home support scheme, the fair deal scheme. I made the point then that crisis after crisis can be expected if we are to continue to operate our health services under the same set of assumptions on which the HSE was established.

We need to look in a rather fundamental way at the delivery of health services but this may be a debate for another day. There seems to be something terribly wrong with the system in this country when, despite warning after warning and crisis after crisis, we seem to be unable to learn the lessons and we seem to wait for the next crisis to be upon us before we act. When action is taken, it seems it is a stop-gap measure to glide over the crisis. We consider it fixed and then profess to be surprised when the next crisis arises. We seem to be almost paralysed in the face of challenges within the health service and we are often too deferential to those whom we regard and they themselves regard as experts. This has happened in the banking, construction and religion sectors and it is also evident in the medical profession.

Senator Burke referred to last November in order to highlight when this problem was first flagged but we can go back a lot further. We cannot say on this occasion that we have not been warned because report after report and committee after committee have predicted the difficulties we now face. I refer to internal memos within the Department of Health, reports from Comhairle na nOspideál, the Postgraduate Medical and Dental Board (Ireland), the Medical Council, the Royal College of Surgeons in Ireland, the Royal College of Physicians of Ireland, the collegiate members committee of the Royal College of Physicians, the Irish College of General Practitioners, the Irish Hospital Consultants Association, the IMO and the Association of Hospital Chief Executives. Herein may lie part of the problem. There is a proliferation of organisations and agencies controlling different elements of activity and categories of medical professionals which gives rise to a competing hierarchy leading to a difficulty in pinpointing the exact locus of responsibility within the health care system. This confusion has not been resolved in any of the changes which have taken place in the past ten years. There is a good argument to be made that the establishment of the HSE without proper reform of the underlying framework has compounded rather than clarified the issues.

I note a report published in July 2005, a career tracking study of the factors affecting career choice and retention of Irish medical graduates. This report notes the significant reliance on attracting large numbers of non-EU students to Irish medical schools. In 2003 the medical school intake for non-EU students was more than 60%, with the Irish Medical Council citing underfunding of undergraduate medical training as the reason. The 2009-2010 annual report of the Royal College of Surgeons in Ireland found that only 30% of medical students are Irish, at a time, as Senator Marc MacSharry observed, when demand from Irish entrants has never been higher. With no improvement in the numbers of Irish students attending medical schools, it is no surprise we are encountering a shortage of appropriately trained doctors to staff our hospitals. When non-Irish doctors are qualified and fully trained, it is natural for them to return to their country of origin. The Royal College of Surgeons in Ireland should examine whether its enrolment policies have contributed to this situation. The 2009-2010 report shows the college has an annual turnover of €180 million and will probably find itself increasingly reliant on the high fees payable by non-EU entrants. This will have implications for the future staffing of hospitals.

There seems to be no alignment of medical training programmes and trainee numbers to meet estimated staffing levels in health services on an ongoing basis. Added to our apparent inability to educate medical students in sufficient numbers to staff our hospitals, we are finding it increasingly difficult to retain doctors after they qualify. In 2005, for instance, 40% of graduates who qualified in 1999 were undertaking postgraduate training overseas. Studies show that concern about the permanent loss of Irish trained graduates to health systems in other jurisdictions is not wholly unjustified. A perceived lack of consultant posts at home, poor working conditions, inflexible working patterns, insufficient training opportunities and a poor work-life balance are cited by graduates as reasons for leaving Ireland. In 2005, 93% of interns indicated an intention to leave Ireland at some point for further training. The well-flagged structural challenges within the system are compounded by a worldwide shortage of junior doctors, with Ireland competing with the United Kingdom, United States, Australia and elsewhere to attract applicants.

We may now have hit a perfect storm. As early as 1993, the Tierney report indicated that non-consultant hospital doctor, NCHD, posts in small to middle-sized hospitals with limited training opportunities are the least attractive to candidates. These hospitals generally do not have a sufficient complement of consultants or the critical mass of work in each speciality to provide appropriate postgraduate training. Nearly 20 years later, this problem is evident in smaller facilities throughout the State, while hospitals where adequate training opportunities exist seem to have little trouble in filling their posts. For example, the paediatric emergency departments in Crumlin, Temple Street and Tallaght hospitals have been able to recruit all required medical staff, while smaller hospitals such as - if I dare to mention it - Roscommon hospital are experiencing severe difficulties. This alone will have major implications for how we deliver health care into the future.

The immediate difficulty facing the health system is the 475 non-consultant hospital doctor posts which must be filled by 11 July. An extensive recruitment drive in India and Pakistan has identified 439 potential candidates, but the Department acknowledges that not all vacancies are likely to be filled. This shortage was flagged some years ago, but the previous Administration did nothing on the legislative side to ensure the situation would not reach such an acute level. As early as January 2010, hospitals were reporting a significant drop in applications from junior doctors, including a reduction of 59% at Tullamore hospital; 56% at Connolly Hospital; 48% at Waterford Regional Hospital; 45% at Cork University Hospital; and 35% at St. Vincent's University Hospital. Eighteen months later we have a situation where only five accident and emergency departments record a full complement of staff for July, while 27 others are reporting significant shortages. Equally alarmingly, there is a shortfall of one in three middle grade doctors or registrars.

The Department has put in train a series of initiatives to address this problem, but it is an issue that must be tackled at a fundamental level. We should not, as was done in the past when other difficulties arose, apply a sticking plaster and pretend the problem is gone away until such time as it next raises its head. The legislation is welcome but it comes very late in the day. As Senator Colm Burke observed, it is of necessity that it is the case. However, legislation that is prepared in a hurry may precipitate some unintended consequences, so we must be careful to get it right. I hope Members will concentrate on this important work and resist the temptation, however strong, to engage in points scoring. That is all too easy to do in regard to the health service.