Dr. Pádraig McGarry:

I will outline the statement on the medical workforce planning to the committee. The Irish Medical Organisation would like to thank the Chairman and the committee for the invitation to discuss the critical issue of medical workforce planning and the crisis in medical staffing, which is having a significant impact on the delivery of healthcare services in Ireland. The Irish Medical Organisation, IMO, is the trade union and representative body for all doctors in Ireland and welcomes the opportunity to highlight the issues of recruitment and retention that exist across our health services in both the acute and community settings.

The main point we wish to make today is that the crisis in medical manpower this country is facing is having severe adverse effects on patients with growing waiting lists and inability to deliver appropriate and timely care. During the austerity years we repeatedly warned that cuts to our health services would lead to a reduction in services, longer waiting lists and an inability to recruit and retain medical practitioners. It gives us no pleasure to say this has now come to pass but we again use this opportunity to call on this committee and the Government to seriously address the deficits that exist in our medical workforce as to do so would improve the overall health of our nation.

The key contributing factors to the current crisis in medical manpower can be identified as including the absence of planning and investment for the number of doctors required to meet the health needs of a changing demographic of patients. Also, Ireland's population is growing but the key factor in terms of planning is the increase in the rate of growth of those over the age of 60. In order to meet the increased but expected needs of the population we need more doctors. To put that in perspective, up to 2008, one in ten patients were over the age of 65, between 2008 and 2028, one in five patients will be over the age of 65 and, by 2040, one in four patients will be over the age of 65. That gives members an idea of the scale of the problem that awaits us down the road. The latest OECD figures show that with 1.44 specialists per 1,000 population, Ireland has the lowest number of medical specialists in the EU, with the EU average being 2.48 per 1,000 population. The HSE's national doctor training and planning, NDTP, office shows approximately 520 consultant posts remain unfilled or filled on a temporary basis while figures obtained by the IMO show that almost half of consultant posts advertised by the HSE in 2018 received few suitable candidates or qualified applicants, or none at all. The demographic of the workforce at specialist level is very challenging with a high level of expected retirements in the coming years. More than 700 general practitioners are due to exit the system in the next five years, a quarter of consultants are due to retire in the next ten years and 50% of our public health specialists are due to retire in the next five years. The direct consequences of this lack of planning are that in many areas such as consultant staffing levels, the staffing levels fall well below the recommended ratios by the national clinical programmes and colleges. In orthopaedics, paediatrics and psychiatry, the consultant staffing levels are 50% below recommended staffing levels while in ophthalmology the staffing levels can be up to 70% lower than what is recommended. More than 770,000 patients are currently on hospital waiting lists. In many areas of the country patients cannot register with a GP due to lack of capacity which has a negative knock-on effect of increased presentations to an already stretched GP out-of-hours service and in emergency departments across the country.

A significant factor is that a poorly resourced health service and a hostile overly pressurised work environment are leading to high levels of emigration of doctors. More than 700 graduates enter basic training each year in Ireland, however, we are training are doctors for export. Since 2015, the number of voluntary withdrawals from the register has almost doubled from 828 to 1,453 in 2018. Data from the Medical Council show that approximately a third are Irish graduates while almost a quarter leave the specialist register. While a small percentage leave to retire, the vast majority, almost 70%, leave to practise medicine in another country. Reasons cited include understaffing, expectation to carry out many non-core tasks, lack of respect, limited career progression, higher earnings abroad, family reasons, more flexible training options abroad, lack of support from employer, longer working hours, poor quality of training and the list goes on. There is a growing body of evidence that demonstrates that doctors are suffering from burnout due to the highly pressurised working environment and this, coupled with a lack of support from the employer, is a significant contributing factor to emigration. Doctors are trained over many years to deliver high quality and appropriate care to patients. The lack of investment in our public health services makes it almost impossible for doctors to deliver that care in a timely manner due to the lack of beds, understaffing, poor access to diagnostics and access to other healthcare professionals, including counselling services, occupational health services and physiotherapy. This starts with GPs being unable to access timely referrals for patients and carries on through to the hospital system or community system with intolerable and dangerous waiting times for outpatient appointments and then in many cases long delays before the prescribed treatment can be delivered. The health capacity report clearly identifies the deficits in terms of infrastructure within the system yet the policy of the Government is to significantly increase investment in the private system through the National Treatment Purchase Fund while starving the public system of the required investment. Our GP workforce is also emigrating. A survey by the Irish College of General Practitioners, ICGP, of GP trainees and graduates in 2017 revealed that one in five recently qualified GPs had already emigrated, while a further 30% of newly qualified GPs were considering emigration. While more than 50% of GP trainees envisage themselves as GP principals in a partnership or group practice in ten years’ time, and that signifies intent, concerns about the viability of general practice, financial prospects and quality of life are the key factors influencing their decision to migrate. It is important to note that the recent GP agreement merely provided a pathway to reinstate the funds lost during the years of austerity and what is required is significant planned investment in the development of GP services for patients.

Another factor is the failure to make our public health services an employer of choice for medical professionals and a culture of disrespect of doctors by the employer and the Government. Our doctors continue to emigrate to health systems that pay more, offer better supports and reasonable working environments and that value doctors.

Over the past five years, the IMO, on behalf of its members, has been forced by the Government and the HSE to take legal action to enforce legally binding contracts entered into by the employer. This has been necessary to ensure doctors work safe and legal hours and to allow doctors to be represented in respect of contractual matters. This does not assist in the development of a culture of respect in which employees are valued. Consultants who were employed prior to 2012 were denied their contractual payments. Those payments were eventually secured on foot of legal action. Consultants who were employed after 2012 were subject to a discriminatory and unilateral cut of 30% in addition to the cuts applied across the public service. The impact of this policy has been the HSE's inability to recruit consultants, which has led to more than 500 vacant posts and more than 100 non-specialist doctors working in consultant posts. Examples of this shortcoming can be seen throughout the country. It has been most recently evidenced by the inability to recruit sufficient consultants for the opening of the first phase of the national children's hospital and the increasing problems in psychiatry services.

Rather than increasing our consultant staffing levels, we are becoming increasingly reliant on foreign-trained doctors. More than 40% of doctors who are registered in Ireland received their training overseas. Research shows that most foreign-trained doctors intend to move on by returning home or migrating onwards. They are concerned about deskilling and are disillusioned by the lack of training and career opportunities. In effect, we are creating a transient workforce in perpetuity. That is not good for the health service or for patients. NCHD contracts are routinely breached by hospitals. Doctors are forced to work in excess of legal hours and are not paid for all the hours worked. Many of them have spoken of poor and inflexible training with poor career progression options. Our research suggests that two thirds of NCHDs perceive pay to be the principal reason for emigrating. Some 83% of them believe the pay disparity at consultant level will be a factor when they are deciding whether to apply for consultant posts in Ireland. The pay disparities between consultants who were employed before and after 2012 are up to €50,000 a year. These colleagues are doing the same job and carrying the same level of responsibility.

Ireland differs from other English-speaking countries because specialists in public health medicine are not remunerated on an equal basis to other consultant specialists in the health system, even though they are required to be on the specialist register and must undergo specialist training. If they were properly resourced, public health doctors could play a pivotal role in commissioning services, analysing health data, conducting needs assessments, assembling the evidence base for interventions, monitoring services and quality-assuring parts of the health service such as screening services. The development of general practice is the cornerstone of many reform proposals, including Sláintecare. Until recently, GPs have been left to shoulder the burden of reduced funding while delivering a greater level of service. There is no clear strategy or funding for the development of general practice. All the factors that have led to this crisis have been much publicised and highlighted by the profession and the IMO for many years. Lack of commitment, investment and respect by successive Governments and the HSE have led to low morale among the existing workforce and high levels of emigration. There is an inability to recruit sufficient doctors to deliver existing levels of care or develop new services. We are at a tipping point. Unless we seriously address this problem, doctors fear for the health service and the safe delivery of care to patients. More reports and promises of reform are not required by the health service and patients. It is not helpful to talk about black holes in the health budget. Contrary to the spin about high levels of health spending, the budget is insufficient to meet the needs of the population. It is time for politicians and policymakers to be honest about this.

Immediate steps must be taken to resolve the medical manpower issue. The discriminatory pay issue for consultants must be resolved. Until this has been dealt with, there can be no new contract discussions, which are required for any reform measures, and we cannot hope to recruit consultants to our public health services. There is no defence for the current policy. The impact of this politically motivated 30% cut has been disastrous for patients and services. There is a need to invest in capacity and supports within general practice to allow it to develop and deliver a fuller range of care in the community. Eligibility for medical cards and doctor visit cards should be expanded on the basis of means or medical need, rather than on the basis of age. The long-held tradition of successive Governments using medical cards as vote-getting exercises must stop.

The training of doctors must be modernised to reflect changes in the practice of medicine and in the demographics of doctors in training. Initiatives are required to bring arrangements for the duration of training into line with international norms. A differentiated model, which provides clearer career paths with greater predictability of training arrangements, responsibilities, locations and working conditions, must be developed in line with the recommendations of the report of the strategic review of medical training and career structures, which is known as the MacCraith review. In excess of 700 doctors enter basic specialist training every year, but an average of just 484 doctors enter higher specialist training. We are just about training enough specialists to replace the number of specialists who leave the register each year. There seems to be a mismatch in the number of posts on offer. Approximately 55 higher specialist training posts are not filled each year in other specialties. There are insufficient training posts on offer to meet demand or the shortage of consultants in that speciality. Vacant posts in public health and community health are putting health planning and the delivery of vital vaccination and screening programmes at risk. The Crowe Horwath report, which was commissioned by the Department of Health, must be implemented to improve the role and function of public health specialists and the training and career structure of public health medicine. Its implementation is required to ensure public health specialists are valued and offered contractual terms in line with other specialists.

Doctors want to work in a system in which they can care for patients. That is why we became doctors. Care delayed is care denied. The cost of denying care has never been assessed in terms of the personal cost to the patient's quality of life, the cost to the system of delivering more expensive and complex care at later stages and the cost to society of days of work lost and benefit payments as many patients await care that will allow them to live full and productive lives. We need reform that makes a difference to patients. Any reform is simply impossible in the context of the current medical workforce crisis. In the absence of significant and appropriate investment, reports and reform proposals are making the situation worse rather than better. There can be no hope of reforming the system, or developing new and much needed services, if the current level of understaffing in the system persists. We must have a system that cares for patients and values doctors. We have seen the consequences of a system that does neither.