Ms Shirley Coulter:

Following our meeting of 20 October 2011 and interim correspondence from the Irish Medical Organisation, IMO, to the joint committee, we welcome and thank the committee for the opportunity to discuss again the continued plight of non-consultant hospital doctors, NCHDs, working in a system which shows an absolute disregard for their contract of employment, appropriate working conditions and future career prospects. Since our previous meeting, very little has changed for non-consultant hospital doctors and little, if any, progress has been made on the Irish Medical Organisation's recommendations to ensure the health service can attract the best doctors and provide excellent training, defined career paths and the highest standard of patient care and safety.

These recommendations, which were discussed in detail at our previous meeting, sought the following: the full implementation of the NCHD contract 2010; improved working conditions and the removal of inappropriate tasks; a reduction in onerous working hours and the appropriate application of the European working time directive; improved structured training in terms of access and funding, including the introduction of more flexible, family friendly training and restructuring of current non-training posts; a strategic planned approach to manpower planning to determine defined career paths for all grades and specialties, including addressing career progression of long service hospital doctors; an increase in the number of specialist and general practitioner posts; and the continued roll-out of clinical care programmes and expansion of primary care to contribute to a reduction in the reliance on NCHDs in staffing hospitals.

Conditions for many non-consultant hospital doctors have deteriorated rather than improved, as ever increasing demands are placed on an overloaded health service, which in turn increases demands on NCHDs who are already working dangerous and illegal hours. Many of these hours remain unpaid by hospitals which unfairly target NCHDs for cost savings, while making no attempt to ensure patient care by reducing unsafe NCHD working hours.

There are a number of grounds for concern about what is taking place. Without doubt, patient care is being jeopardised in a system which routinely expects doctors to work excessive hours without adequate breaks or rest. Despite the best efforts of non-consultant hospital doctors, who take their responsibilities extremely seriously, it is clear that an accident will happen as a result of the current working regime and it will have serious, perhaps even fatal, consequences.

The health of our members is also being jeopardised. We have recounted previously before the joint committee stories of mental and physical health issues arising for non-consultant hospital doctors purely as a result of the excessive working time arrangements to which they are subject. The future of our health services is being jeopardised as more and more of our best and brightest young doctors turn their backs on a system that is chaotic and shows little interest in their well-being.

As I indicated, the position has not improved despite increased debate and attention on this crisis. The unilateral introduction in September 2012 of the consultant pay cut and corresponding two tier work force as well as the recent Croke Park II agreement, which inequitably adversely impacts on non-consultant hospital doctors, are further retrograde steps that will only serve to exacerbate the problems of recruitment and retention of NCHDs in the health service. While the Government appears to have seen the error of its way in establishing, de facto, a two tier public sector by seeking to address the new entrant pay cut introduced in January 2011 as part of the Croke Park II agreement, this does not address the issue for non-consultant hospital doctors as the new entrant consultant pay cut is to remain. This is yet another anomaly that will drive NCHDs out of the health service.

Doctors may choose not to complete lengthy training in a health service that disregards their contract, requires onerous illegal working hours under difficult working conditions and has limited career planning without the prospect of a consultant post remunerated at a level equivalent to the consultant they will work alongside. Non-consultant hospital doctors may instead pursue shorter training overseas under superior conditions, with the aim of taking up a consultant post that provides an overall package of terms and conditions of employment, working conditions and salary levels that are more attractive than those available in Ireland. This is best exemplified by the Irish Medical Organisation's "Boarding Pass" campaign of November 2012, which resulted in more than 800 non-consultant hospital doctors indicating their intention to leave the health service by signing a symbolic boarding pass to make the point that unless the position changes, there will be more NCHDs in our airports than in our hospitals. The impact is already being felt, with the Health Service Executive having to re-advertise almost 20% of consultant positions last year.

In addition to the foregoing detrimental developments since our previous meeting, the debate on the implementation of the European working time directive has been reignited. As outlined in our previous submission, the non-consultant hospital doctors contract 2010 and High Court settlement agreement between the Irish Medical Organisation and Health Service Executive of January 2010 both allow for the flexible application of the directive to NCHDs, including a maximum on-site shift of 24 hours, on a 1:5 basis, and the recording of time separated into working and training time. Due to the failure of the HSE to implement these provisions, the European Commission forwarded a reasoned opinion to Ireland on 30 September 2011, stating that non-consultant hospital doctors work average hours which exceed the limit fixed by the directive and are not provided with minimum daily and weekly rest in accordance with the protections in the directive and requesting an explanation for this non-compliance. In January 2012, Ireland submitted a . This plan affirms Ireland's commitment to achieving compliance with the directive, sets out a timeframe for achieving compliance over the next three years, identifies the establishment of a national high level implementation group and commits to implementing other measures that will support compliance, including the implementation of new work patterns for medical staff, transfer of work undertaken by NCHDs to other grades and organisation of hospital services to support compliance with the working time directive. It also makes a commitment to provide the Commission with an annual progress report.

This response is being considered by the European Commission and the Irish Medical Organisation understands a case may be taken against Ireland in the European Court of Justice. The IMO has also written to the Commission to highlight inaccuracies in the HSE’s report and we lodged an official complaint in March 2012 that national law and practice in Ireland does not comply with the working time directive. Our complaint is registered with the Commission and is being considered.

The Health Service Executive published a report on European working time directive compliance and related issues dated 30 January 2013. It includes 15 national standards for European working time directive compliance on which hospitals were required to report by 1 March 2013. These standards were drafted without any consultation or agreement with non-consultant hospital doctors or the Irish Medical Organisation, despite our repeated calls, including under the auspices of the Labour Relations Commission, for the issue of the European working time directive to be properly addressed by the HSE. The standards are largely impractical and non-implementable within the timelines set out, particularly without the direct involvement of non-consultant hospital doctors. It is likely that the premature issuing into the system of these unilateral proposals with an unworkable deadline for the submission of an action plan will only produce responses that highlight the impossibility of implementation, rather than any coherent action plans.

It is the stated position of the Health Service Executive that responsibility for improving European working time directive compliance remains at individual hospital and agency level. While this is undoubtedly an unacceptable abdication of responsibility by the HSE nationally, to achieve compliance it will be essential to secure the buy-in of all stakeholders, including at local hospital level. However, the lack of any sanctions for non-compliance, coupled with an overriding concern for budgets over patient and doctor health and safety, results in a total lack of accountability at both national and local level for the consistent and dangerous flouting of the law every day in hospitals. The HSE hides behind inaccurate averages of working hours, stating that non-consultant hospital doctors are working on average 54 hours per week. The IMO disputes this figure and from our own data, it is clear that the average is between 60 and 65 hours per week. The HSE use of averages is totally inappropriate, however, given that the European working time directive applies to individual doctors, and serves only to mask the true extent of the dangerous working hours required of NCHDs, many of whom work in excess of 100 hours per week and complete continuous shifts of up to 72 hours on site, often without appropriate rest or sustenance.

We are all well aware of what the problems are because they have been debated in detail in recent years and resulted in myriad reports and recommendations, all of which have been to no avail. The focus now must be on solutions, not problems. The key objectives of the current NCHD campaign, #24hoursisenough, which is borne out of non-consultant hospital doctors' absolute despair at the soul-destroying hours they are required to work to the detriment of patient care, are to limit the maximum shift length to 24 hours, limit the weekly average to 48 hours in compliance with the European working time directive, while protecting training time, and remove NCHD inappropriate tasks. To this end, it is of utmost concern to the IMO that there is a complete absence of a proposal in the HSE's 15 national standards to address the key issue of the removal of NCHD inappropriate tasks, which would undoubtedly significantly reduce NCHD working hours and would be a major stepping stone on the road to compliance with the European working time directive.

A recent survey of non-consultant hospital doctors found that more that 30% of their working time is spent on tasks which are not appropriate to an NCHD and should be undertaken by other grades of staff in order that non-consultant hospital doctors can focus on their medical work. These include the administering of first dose intravenous medications, phlebotomy, cannulation and ECGs, none of which should require a doctor. At weekends, NCHDs can spend in excess of four hours undertaking routine phlebotomy, which amounts to 208 hours or in excess of five working weeks per year.

The national implementation group report on the European working time directive of December 2008 recommended the promotion of multidisciplinary health care collaboration between health care professionals, including the redesignation of existing roles. It found that the delegation of non-medical duties to grades other than non-consultant hospital doctors can facilitate reductions in NCHD hours, allowing NCHDs to focus on other aspects of medical care and thereby improving the efficiency of service delivery.

The pilot projects undertaken showed a willingness and flexibility by NCHDs and other health care staff to embrace change work practices, yet there has been no move by the HSE to implement these work practices in the intervening years. While a number of hospitals already have local policies and custom and practices well established with regard to many of these tasks, it is clear that a national policy on NCHD inappropriate tasks and a redefinition of the duties and responsibilities of NCHDs must be agreed with the IMO as a matter of urgency, with a practical timeline for its implementation.

With regard to the other key objectives of the "24 hours is Enough" campaign, national agreements are already in place and the HSE must facilitate formal national liaison with the IMO and local level engagement between NCHDs, hospital management and senior clinicians to agree the reorganisation of rosters. The problems are evident and the solutions are clear. The HSE must accept its responsibility to doctors and patients alike to ensure that safe work practices are implemented in all hospitals without delay. The IMO, the representative body for NCHDs, is ready and willing to work with all stakeholders to ensure the essential changes to the day-to-day work, training and career paths of NCHDs are achieved in a timely fashion to safeguard the highest standards of patient care in the Irish health service into the future.