Dr. Donal O'Hanlon:

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

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

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

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

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

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

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

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

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

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

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

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

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