Oireachtas Joint and Select Committees
Tuesday, 5 March 2013
Joint Oireachtas Committee on Health and Children
Pay and Conditions of Non-Consultant Hospital Doctors: Discussion
2:00 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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Ba mhaith liom failte a ghabháil le baill Ceardchumann Dochtúirí na hÉireann agus Feidhmeannacht na Seirbhíse Sláinte. I welcome the members of the non-consultant hospital doctors subgroup of the Irish Medical Organisation. I also welcome the officials from the Health Service Executive who will address the committee during the second part of the meeting. Tá an Comhchoiste um Shláinte agus Leanaí ag caint mar gheall ar choinníollacha fostaíochta na ndochtúirí neamh-chomhairleacha ospidéil. This afternoon, we are discussing the conditions and services of non-consultant hospital doctors as part of our work programme.
I remind people in the Public Gallery and the members of the committee to switch off their phones. We have agreed to defer our consideration of the minutes and the comhfhreagras to the cruinniú maidin Déardaoin. Apologies have been received from Deputies Ciara Conway and Robert Troy and Senators Imelda Henry and Jillian van Turnhout for their absence from this afternoon's meeting.
The subject of the first part of this meeting is the pay and conditions of non-consultant hospital doctors. In the second part of the meeting, we will discuss recruitment policy. It is important that we hear the views of all sides on this important issue. During the past week, we have seen a number of commentaries in one of our newspapers regarding the conditions of non-consultant hospital doctors.
I welcome to the first part of the meeting Ms Shirley Coulter, who is the assistant director dealing with industrial relations of the Irish Medical Organisation. She is joined by Dr. Mark Murphy, who is the chairperson of the organisation's non-consultant hospital doctors committee and has been with us before, Dr. Shane Considine, who is a senior house officer at Our Lady's Children's Hospital in Crumlin, and Dr. Grainne O’Kane, who is a specialist registrar in the medical oncology unit at the Mater Hospital. They are very welcome to this afternoon's meeting. I thank them most sincerely for being here, especially as I understand some of them have had to change their schedules to accommodate our meeting.
Before we begin, I would like to remind members and witnesses of the position regarding privilege.
I advise witnesses that by virtue of 17(2)(l) of the Defamation Act 2009 witnesses are protected by absolute privilege in respect of their evidence to the committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a Member of either House, a person outside the House or an official by name or in such a way as to make his or her identifiable. I remind members of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.
An apology has been received from Deputy Billy Kelleher. I invite Ms Coulter to make her opening statement.
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.
2:10 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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Go raibh míle maith agat. I thank the witness for an interesting and challenging presentation.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome the IMO representatives and the further address of the employment conditions and role of non-consultant hospital doctors. I have often thought it a curious thing that we describe a cohort of health professionals by what they are not, as against what they are. In any event it has been known and widely recognised for many years that the hospital system is over-reliant on non-consultant hospital doctors and successive Governments have clearly failed to address this over-reliance. It led to the crisis faced in 2011 which led to emergency legislation in order to address the significant shortfall in supply. At that time, I recall the Bill facilitated the continuation, at least for the time being, of the current system and at least it prevented the collapse and the consequent loss of services. One would have to ask how long we have to wait for real reform of the situation and when the ramshackle structure, which is how I described it at the time, will be replaced by a proper system of medical training and hospital staffing.
The presentation goes to the core of the issue. The witness pulled no punches, for which I say, "Well done". It is very important that we have a wake-up call. One would have to ask what is the Minister for Health's plan to end the reliance on non-consultant hospital doctors and to get better value for patients and whether he has such a plan. This is critically important. The system was flawed enough but has been compounded by the recruitment embargo and the widespread cutbacks which are being imposed making an already difficult situation infinitely worse. In the context of all this, the IMO update today, which is an update on the last submission on 20 October 2011 which was the last time we engaged on the issue, makes what I have described in my notes as grim and alarming reading. I wish to emphasise again what the witness has put on the record. We are told that little, if any, progress has been made since the last time we engaged some 18 months ago. This is March 2013 and conditions have clearly deteriorated. We are told that NCHDs are working "dangerous and illegal hours". Most significantly, I note the IMO says patient care is being jeopardised and that an accident will happen as a result of this working regime and it will have serious and, perhaps, fatal consequences. The witness spoke of "consistent and dangerous flouting of the law" every day in hospitals around the country. So far as patient safety and care is concerned, as well as the well-being of hospital staff, of its own professional involvement, I believe it is an indictment of the Minister that there has not been a substantive address in the period since we had a huge focus on the issue in mid-2011. I wish to ask a couple of questions.
The IMO recommends removal of inappropriate tasks from NCHDs. Is this compatible with the Irish Nurses and Midwives Organisation's proposals for expanding the role of nurses? I do not have to go over the detail of the IMO proposals as the witnesses are already familiar with it. What does the IMO see as the next essential step? What would it recommend should be done immediately? I hope we as a committee will set aside all our differences, whatever our views of the Minister, and I have expressed mine. I believe we have to address the issue together and urge immediate action because this is not tenable and cannot be tolerated further.
John Crown (Independent)
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Go raibh maith agat. I warmly welcome my colleagues. I remember my own days as a trainee doctor, as an NCHD, with a mixture of the odd sleepless night and what it was like to be on call for three or four consecutive nights. I also recall it with a degree of nostalgia about the excitement of first being involved in our wonderful specialty. A couple of weeks ago we had the vote on the Irish Bank Resolution Corporation Bill. This rare event occurred when Deputies and Senators had to stay up until about 2.30 a.m. in the case of the Deputies and the more hardy Senators were up until about 6.30 a.m. The most complicated thing they had to do at the end was to push a green or red button and, in most cases, had been told what button to push. There was nothing more complicated than that. There was a certain amount of whingeing the next day when people had to do other aspects of their job as well. This is just the every day and every night experience-----
Jerry Buttimer (Cork South Central, Fine Gael)
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Some of us on this committee were here at 9.30 the following morning. For the record, we were not missing.
John Crown (Independent)
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I was here as well. What is more I went to the hospital where I was working until 10 p.m.
Jerry Buttimer (Cork South Central, Fine Gael)
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Working in the hospitals is-----
John Crown (Independent)
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We can compare views later. We are not in a competition right now.
Jerry Buttimer (Cork South Central, Fine Gael)
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Good, I am glad the Senator has qualified his remarks.
John Crown (Independent)
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The issue is that this is the every day and every night experience of junior doctors all around the country where they are expected to work like that. They do something far more complicated than doing what a Whip tells them in terms of voting "Yes" or "No". They actually have to make life and death decisions. Deputy Ó Caoláin correctly pointed out the oddity of referring to them as non-consultant hospital doctors. Previously they were known as junior hospital doctors. However, when it became apparent that the average age of a registrar in this country was the late 30s and the average junior hospital doctor had ten to 15 years of medical experience, following medical school under their belt, and that on average they waited until they were in their 40s for a consultant job, which in any normal country, with a normal health service, they would have had a decade earlier, it became apparent that calling then junior doctors was inappropriate. This goes to the core of the problem. Trainees should be trainees. If I ran the system I would refer to them all as trainee specialists. That is what they are. Senior hospital doctors, interns, registrars, all with varying degrees of seniority, are there to learn and to train. Instead of that, we have used them as a colossal band-aid to plug the fundamental gap in our health service which is the appalling shortage of career level jobs both within and without hospitals. We have the smallest number of consultants in every specialty and the smallest number of GPs. As a result if people are to get medical care, one has to inappropriately use trainee doctors. As well as that there was a culture where our trainee doctors were encouraged to go to international centres of excellence to advance their careers and to bring skills back to our country.
Instead, I believe what has happened is that the domestication of training in this country has been an attempt to institutionalise people, keeping them here for four, five, six or seven years after medical school to be service providers. The royal colleges and, to an extent, the Medical Council, have been somewhat complicit in this.
I beg the committee's indulgence, but I may have to leave to deal with an issue in the Seanad. The key solution to these problems would be to have appropriate reform of the health system. People should know coming out of medical school that they will have to do this for five or six years, but that after that they will have a career level job. They should know there will be no pressure on them to emigrate or no uncertainty about the outcome. They would do their five or six years in that case. It is because we keep them in endless abeyance, not knowing whether they will be "junior doctors" or "trainees" when they are already a decade past full training that they tend to regard themselves just as service providers.
We urgently need to fix the safety issues relating to the non-compliance by the State with international guidelines and international and European directives. However, to fix the bigger picture, we must fix the health system. We must have a system where we have an approximate trebling or quadrupling of career level posts, a reduction in trainee posts, a match of career posts to trainee posts and a situation where, when a person finishes medical school and has done his or her training, he or she will have a job.
2:20 pm
Colm Burke (Fine Gael)
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I had to make a difficult decision earlier as there is a restriction put on us Senators with regard to turning up to committees while the-----
Jerry Buttimer (Cork South Central, Fine Gael)
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There is a set time for the committee.
Colm Burke (Fine Gael)
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I know, but I had to make the choice as to whether I should attend the committee, as did Senator Crown. I thought it was important to be here to discuss this issue as I had called for it to be debated by the committee and I thank the Chair and the committee for accommodating me.
Several issues arise in the context of junior doctors. What level of consultation is taking place currently between managers and junior doctors in hospitals with regard to the difficulties junior doctors have in individual hospitals in the context of working time and conditions? Is there any consultation taking place? In 2011, we had a major crisis when a situation arose where the HSE had to go to India and Pakistan to recruit junior doctors and I understand that well over 200 of those doctors came and got jobs here. Their two-year contracts will expire in July or December this year and I understand they will not be offered any job within the HSE once the two-year period is up, although they will have got used to the system here. Is that correct?
My office conducted a survey on the attitude of medical graduates graduating in June 2012 and some 65% of them indicated they would not be working in Irish hospitals after June 2013. Can the witnesses give us any indication of the number of those now working as interns who intend to stay working in the Irish health system? What percentage of them intend to stay? In the case of existing junior doctors, will a larger number of these be leaving in June and December this year in comparison with other years? Has the IMO any indication of whether the percentage of those who intend to leave has increased?
I understand there are some discussions taking place with regard to the recruitment of junior doctors from Pakistan and that this process will be different from the supervised division that operated in 2011. Has the HSE discussed that issue with the IMO and what rules will apply for these people? I raise this because I am concerned that we are prepared to engage with a foreign country on recruitment - I have no difficulty with regard to people from Pakistan and India working here - but do not seem prepared to sit down with educational institutions here and do the same. Does the same level of consultation take place with Irish educational institutions?
I understand there are over 4,000 junior doctors working in the Irish hospital system. Has the IMO any idea how many of these doctors are on six-month, 12-month, two-year or three-year contracts? When I put this question to the HSE, I was unable to get an answer. Does the IMO have that information? It would be helpful to this committee.
John Crown (Independent)
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I would like to put a brief supplemental question. Over 50% of non-consultant doctors working in Ireland now are not Irish graduates but come from abroad, yet we have the largest number of medical schools per head of population of any country in the world. Why is this? Recently, I heard of an extraordinarily well-trained colleague, with 18 years international experience, multiple publications and who is a true leader in his field, who has failed in every attempt to get a job in Ireland and has just been recruited by Harvard Medical School.
Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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In a way I am very uncomfortable debating this issue, because my son is a doctor. However, I know for a fact that junior doctors are working those hours. My son works day and night; he never gets home and it is really tough.
Professor Crown put the facts in his supplemental comment. I do not get it. We train doctors, but we do not give them jobs and export them. The taxpayer forks out the money for this.
Jerry Buttimer (Cork South Central, Fine Gael)
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I just wish to inform members that the HSE will be here for the second part of our meeting.
Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I find it very difficult to understand the situation. I am concerned that what is going on is a danger for patients, particularly when doctors must work 72 hours or so without sleep. I am concerned about sleep deprivation and the dangers it brings. I cannot understand why we are bringing in foreign doctors when we have our own doctors here.
The IMO stated that we must match production to replacement value and that while there is no guarantee of the chosen career path of any non-consultant hospital doctor, we should, at the very least, be producing the required number of specialists in Ireland, rather than recruiting them from developing countries in contravention of the World Health Organization guidelines on ethical recruitment. I do not understand how this is working. Will the IMO explain it for the benefit of the committee?
Mattie McGrath (Tipperary South, Independent)
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I too welcome the witnesses and I wish to acknowledge the honesty and integrity they bring to their presentation today. I welcome the comments made by Senator Crown and Deputy Mitchell O'Connor, who have direct experience of the situation. It seems we can defy every recommendation, rule and European directive in the book when it suits us. I am aware the HSE will be coming before the committee later and I hope to question it in this regard.
All over the country, including in my county, HIQA is looking at buildings and declaring them unfit for use, unsuitable and too old and Dickensian. However, there is no organisation such as HIQA in place to look after staff who are being abused, professional staff who have had top-class training and who want to and are giving their all, but who have to work under these kinds of conditions. When are we going to get it right? In the case of buildings, standards are being enforced and places are being closed, but there is no body looking after the well-being of our willing, able and hard working junior doctors who are forced to work under these conditions. This does not happen elsewhere. It does not happen in industry, in agriculture or anywhere else. In those areas health and safety rules are observed as are working time rules and employment regulations and legislation.
Why is this allowed go on by the Department of Health and the HSE? I fully support the witnesses and agree what they are being asked to do is outrageous. How can going the length of time they do without sleep not be a danger to both them and patients. No matter who we are, we cannot manage without rest.
It is farcical that this can continue, in spite of what HIQA is doing in both private nursing homes and public hospitals. It exposes huge disrespect for human beings, both patients and doctors.
2:30 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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HIQA is not involved in this issue, as the Deputy knows.
Mattie McGrath (Tipperary South, Independent)
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I am not saying that.
Jerry Buttimer (Cork South Central, Fine Gael)
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That is why the European working time directive was brought in, as the Deputy also knows.
Jerry Buttimer (Cork South Central, Fine Gael)
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Yes. Ms Coulter can share time with her colleagues, if she wishes.
Ms Shirley Coulter:
I will do so. I will take the questions in order and group them together, where appropriate.
Deputy Caoimhghín Ó Caoláin asked about the next steps and the compatibility of our views on the next steps vis-à-vis appropriate tasking with reference to nursing staff and so forth. We are not reinventing the wheel. There is already significant custom and practice around the country, whereby other grades of staff, not just nursing staff, are undertaking these duties and it is a matter of looking at where it works and developing national guidelines. These guidelines should be developed collectively. It is important that the HSE, the IMO and doctors work together, with the representative bodies for the other groups.
The committee may already be aware that the IMO works alongside the INMO, where appropriate. Both organisations left the Croke Park II discussions recently and are collaborating closely on many issues. We have had informal discussions about these issues. I welcome Senator John Crown's comments and agree that appropriate reform of the health system is absolutely necessary, but it is probably a longer term goal, given the major patient and doctor safety implications. We need quick win solutions and things to happen now. Some of the key measures we are examining will achieve this. One of them is the introduction of a maximum 24 hour on-site shift. Another involves the removal of inappropriate tasks.
As some of the doctors might like to speak, I will hand over to Dr. Murphy. Dr. O'Kane has been very involved in securing the local engagement required to effect real change in a number of hospitals and will speak about that issue after Dr. Murphy has contributed.
Dr. Mark Murphy:
I extend my gratitude to Deputies and Senators for their support in advocating the rights of non-consultant hospital doctors in the past 18 months. I also thank the committee for giving us the opportunity to speak today. I will be very direct. NCHDs have absolutely horrendous working conditions. Hospitals are not what they used to be in the 1980s and 1990s. There are chronic diseases, an aging population and treatments that were not available then such as for heart attacks. Hospitals operate 24 hours a day, seven days a week, 365 days a year and NCHDs provide care on that basis. Hospitals are, wrongly, entirely reliant on NCHDs to provide that care.
Jerry Buttimer (Cork South Central, Fine Gael)
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Was that not always the way? Senator John Crown suggested it was always thus.
John Crown (Independent)
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It was always the way in Ireland.
Dr. Mark Murphy:
Yes, but working a 100 hour week 20 years ago was not the same as working an 80 hour week today. That 80 hour week is a sleepless one, involving stress and multiple life and death decisions. The average working week is approximately just over 60 hours, but we all know what averages mean. The outliers are working absolutely horrendous hours that would not be inflicted on a dog. Everyone in the State, however, including the Government and our employer, the HSE, is happy for us to do this, but enough is enough and NCHDs have spoken. It harms our physical and mental health, harms patients and the future of the health service. What are we going to do about it? Are we going to have another Hanly report or another expert group report? The HSE is our employer and I hope the committee will ask it for some accountability.
Deputy Caoimhghín Ó Caoláin asked about the essential steps and Senator John Crown referred to the big picture, long-term issues such as the fact that we need more consultants and a reconfiguration of hospital services. We can talk about the difficult changes that need to and should happen in the longer term, but we also need to address the issue of changes that can be made this year. I hope the committee will press the HSE to make these changes. In that context, I will reiterate what Ms Coulter said. First, on the issue of NCHDs and appropriate tasks, the situation is ludicrous. The Minister for Health has described us as "gofors". Is that what the State is training us to be? We have NCHDs who ensure already booked investigations happen. Why? That does not happen abroad. It is not very difficult to sort out this issue. One only has to look at the situation in Australia, New Zealand and other countries where there are six consultants for every two NCHDs. Here, we have one consultant and myriad NCHDs running after him or her, carrying out inappropriate tasks. Reform and change must happen and Dr. O'Kane can expand on how that can be done. Ultimately, though, it is up to the HSE to make change happen. The issue is one of accountability. Those at the top end of the human resources section say they agree with us, but it is not trickling down. Accountability and a change to the culture are vital.
The second issue is rosters which could be changed this year. The IMO and NCHDs need to be involved with local management to make this happen. It is within the gift of the HSE.
These two changes alone would dramatically reduce the hours worked by NCHDs, improve our health and that of our patients, as well as help in the retention of doctors in the system. The health service would be better and the taxpayer would win because we would not be claiming un-rostered overtime that we do not want to work. These two changes, namely, changing our roles and using clever rostering systems, must happen and we must be directly involved. As Ms Coulter outlined, we were not even consulted about various changes that were supposed to take place by 1 March, none of which has actually happened. We must be involved in the process because we have the expertise required to make positive changes.
Jerry Buttimer (Cork South Central, Fine Gael)
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Is Dr. Murphy saying there was no consultation with NCHDs at local level by any hospital management or the HSE on working conditions, rostering, overtime and so forth?
Jerry Buttimer (Cork South Central, Fine Gael)
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Is Dr. Murphy saying ---
Jerry Buttimer (Cork South Central, Fine Gael)
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There has been no communication, no sitting around the table and no consultation. Is that correct?
Dr. Mark Murphy:
We meet the HSE, as Ms Coulter will explain, but in terms of implementing policies, there has been nothing. We meet the HSE and talk about policies. The head of human resources agrees with us at these meetings, but change is not trickling through. Changes are not happening on the ground.
Jerry Buttimer (Cork South Central, Fine Gael)
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In the context of changing the rostering arrangements and hours worked, is there a need to introduce a clock-in, clock-out system, whereby doctors would have to leave at designated times? There was a big controversy involving Cork University Hospital, detailed in various newspapers this week, about forms and payments. Is it the case that doctors decided to stay, rather than go home, after they had worked their rostered hours? I raised this issue at a meeting of the health forum in Cork yesterday.
Ms Shirley Coulter:
To address what Dr. Murphy is referring to, a document detailing 15 national standards, I have a copy of the document which I can share with the committee, although I am sure the HSE will distribute it later. It is entitled, Assessing Performance in Reducing NCHD Working Hours - National Standards. Essentially, these are 15 national standards developed by the national working group on the European working time directive which was established last year. The IMO requested that it be involved with the working group. We had one meeting with the group in May last year and have not heard anything from it since, despite raising the matter on numerous occasions. We are constantly engaged in discussions with the HSE under the auspices of the Labour Relations Commission and raised the question of the working group a number of times.
The document, with the 15 standards, was drafted by the aforementioned working group without consultation with the IMO, as the representative body for NCHDs. Furthermore, it was drafted without local level engagement with doctors working on the ground. It is my understanding that a number of site visits were conducted around the country as a data gathering exercise. The working group saw, for example, that certain specialties with a certain number of doctors were working well and in near compliance with the directive, while others with similar numbers of doctors were nowhere near compliance. It seems that the working group tried to come up with a sticking plaster solution by taking what worked in one area and trying to apply it across the board.
It will never work without the proper and appropriate local-level engagement of doctors who are actually in place. The HSE should bear in mind that buy-in from doctors will be required to work these new rostering arrangements. For doctors to feel that they have ownership and some control over what they are doing, it is necessary that they are involved in the rostering process.
Dr. Murphy referred to standards and we referred to them in our statement as well. It is concerning that a key recommendation of the Hanly report from 2003, which is Government policy, and a key recommendation of the HSE's report on European working time directive, EWTD, compliance relates to the removal of inappropriate tasks from non-consultant hospital doctors, NCHDs. There are 15 standards for achieving the EWTD but the report mentions nothing about the tasks, duties, roles and responsibilities. The HSE is following through on its stated policy when it comes to implementation. This was issued throughout the system and hospitals had to report back by 1 March on how they would achieve compliance. This occurred with no consultation with NCHDs. We held a meeting with NCHDs and some HSE senior management attended. After that I received an e-mail to stating that the HSE would now engage with NCHDs but it is a little late for that. They had already drafted the standards. We will be calling for the withdrawal of these standards, for everyone, including all the stakeholders, to get around the table to ensure that national standards are implementable and achievable and that they will effect real change. These must be drafted and implemented with the required urgency.
Reference was made to clock-in systems. The Irish Medical Organisation, IMO, and several hospitals have agreed to the introduction of clock-in systems and they are working well. That is one of the objectives of the national standards and one we are willing to discuss with the HSE. It is absolutely untrue and it is disappointing to hear that there is an indication that NCHDs might be claiming for hours that are not worked.
2:40 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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I did not say that.
Jerry Buttimer (Cork South Central, Fine Gael)
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The issue was that they were staying longer to carry out ward rounds with the consultant.
Ms Shirley Coulter:
My apologies. The suggestion is that they were staying longer than they should have. The issue is what they should be doing. They must stay as long as a service requirement exists. As Dr. Murphy remarked, hospital services are provided on a 24 hour, seven day basis. I cannot say that my roster ends at 5 p.m. and therefore I am simply going home at that stage. The patient still needs to be seen and taken care of. Often, this is why NCHDs stay beyond the roster. There is an anomaly in NCHD working lives relating to unrostered hours and the Chairman referred to a relevant situation in Cork. These hours are unrostered because the roster is not appropriate to the actual working day. The roster is based on coming in at 9 a.m. and finishing at 5 p.m. but that is not how the service is delivered. A ward round might start at 8 a.m. or there might be a team meeting starting at 7 a.m. or a clinic may be meant to finish at 5 p.m. but it may not finish until 6 p.m or 7 p.m. These hours are classified as unrostered. They are inevitably crossed off when people claim them but the NCHDs are absolutely required to be there. They are there at the behest of the employer and they are there to provide a service.
Dr. Grainne O'Kane:
I wish to echo Dr. Murphy's comments and I thank the committee for having us here this evening. I wish to put things into some context following what Ms Coulter has said. Seven years ago as a student I was asked to shadow some of the interns in a particular hospital and document the inappropriate tasks on call. The work was documented seven years ago but nothing has been done with those inappropriate tasks since then.
Senator Burke commented on management and NCHDs. I have come to realise in recent years that in Ireland there is a huge missing link between administration, allied health staff and NCHDs. Undoubtedly, we are best placed to serve people because we can see the inefficiencies in the system since we work on the ground. We are also well travelled and we have worked in various hospitals throughout the country. For such a small country we have a rather variable health system and things are done differently in different hospitals. As a result of these observations made over my five qualified years, two years ago I established an NCHD committee in one particular hospital for several reasons. Following this, we held several meetings with nursing staff and we progressed several issues relating to inappropriate tasks. We developed a collaborative document with nursing staff on a policy and we began to implement a pilot scheme on the administration of first-dose antibiotics by nursing staff. I believe that has progressed although there have been several teething problems.
We have another NCHD committee in my current hospital. We are working on several issues including inappropriate tasks and rosters. Also, we have NCHD representatives linking and infiltrating throughout the hospital. We now have several representatives on the HSE clinical programmes within the hospitals. We meet regularly with human resource and administrative staff to consider the issues involving NCHDs. A good deal of work has been done. In recent months, given the current climate we have advocated that NCHD local committees are potentially the way forward on a short-term basis. Certainly, one size does not fit all situations. I have worked in several hospitals throughout the country. If one implements a given roster in one hospital, one can be guaranteed that it will not work in another hospital.
This brings me to another point. Workforce planning throughout the country is something we should work to improve. Communication is vital but it is possible to improve things. The culture of Ireland is such that decisions that involve NCHDs are unilaterally taken by administrative staff. No one seems to consult the NCHDs. I believe that we are best served to consider the inefficiencies and to improve the system. Anyway, it can be done.
Dr. Shane Considine:
I wish to express my thanks for having us here this afternoon. The issue of accountability is relevant. The longer we continue to neglect to sort out fines or penalties for failing to implement the systems that have already been agreed upon, the longer the problem will continue. Recently at a public meeting with us the HSE described itself as exploiting us as a workforce. That is a direct quote.
Jerry Buttimer (Cork South Central, Fine Gael)
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When did that happen?
Dr. Shane Considine:
That happened approximately two weeks ago at an IMO industrial relations meeting. I echo Deputy Mattie McGrath's words: we are forced to work these hours. Colleagues from other fields often ask why I do not simply leave at the end of a day but as a doctor I have a duty of care to my patients. If I have a patient who is unwell at 5 p.m., I do not leave. I must ensure that my patient is appropriately looked after. That is my priority and it will continue to be my priority.
I welcome the clock-in and clock-out system. I have worked in a hospital where it was implemented rather successfully. However, it is clear that this system records hours but it does not necessarily ensure that these hours are within the documented limits as per our contracts and as per the recommendations of the European working time directive. Anyway, it means those in the human resources department have an objective and clear record of exactly how many hours each doctor is working but they are completely ignoring these records in the vast majority of cases.
Jerry Buttimer (Cork South Central, Fine Gael)
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How do you overcome that?
Dr. Shane Considine:
We must engage with the individual human resource departments at a local level. More engagement with local NCHD committees, as Dr. O'Kane described, and the various hospitals is needed. We have seen such committees spring up in recent weeks as these issues have gained more traction and public airing. In the past certain hospitals may not have had committees but they are now developing committees, meeting regularly, engaging with management and becoming involved in decision-making and planning. That is a key change.
Jerry Buttimer (Cork South Central, Fine Gael)
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Has there been engagement with consultants?
Jerry Buttimer (Cork South Central, Fine Gael)
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Why not in all of them? Surely, they are key players in this process as well.
Dr. Shane Considine:
Absolutely but, unfortunately, consultants have been left with a good deal of the blame on this matter. The HSE is deferring much of the responsibility for implementation of issues relating to the working time directive to consultants. Naturally, consultants are important in this process and we are keen to engage with consultants in every hospital.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I will be brief. I apologise for being late; I was speaking in the Dáil. I welcome the doctors. My last direct involvement in the hospital service was approximately 15 years ago. It was an issue then and clearly it remains an issue. It is a more serious issue now because as the doctors have said the complexity of the work and the workload is entirely different today from what it was ten or 15 years ago. There is no comparison with the type of work, the level of work or the complexity of the work that is done at this stage. I can confirm from my experience the veracity of the comments on rosters. The fact is that in most hospitals the published rosters bear no resemblance to what junior doctors work at and the hours they put in. As the doctors have said, in many cases they may start at 7.30 a.m. or 8 a.m. depending on the time the consultant starts his rounds, on how long the clinics last and how many additional patients are added to the clinics.
There is no comparison between the published rosters and the actual work done and hours worked by junior doctors. It is another indication of the head in the sand attitude of the HSE. I am in agreement with the point raised by the doctors in their submission that the key difficulty with the HSE in this and quite a number of other areas concerns the lack of consultation. It is appalling that in a whole range of issues the HSE simply refuses to consult stakeholders, people on the ground, staff and others who have a genuine interest and stake in the delivery of services. That is a fundamental difficulty. Until we solve that problem, there will be significant difficulties right across the health service, not just with regard to non-consultant hospital doctors.
2:50 pm
Colm Burke (Fine Gael)
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I refer to my questions about attitudes to junior doctors. Their contracts finish in June or December this year. Is there any indication of how many, particularly interns, do not intend to reapply for jobs in the HSE? Does the IMO have any indication whether the 200 doctors from India and Pakistan will be offered contracts once their two years are up? I presume they are represented by the IMO and that they are working here under supervision.
Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I asked about career progression. To put it bluntly, why are we importing doctors from other countries and exporting our own for whom taxpayers paid? I would like an answer to this question.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I ask the panel to comment further on the point made in the submission delivered by Ms Coulter. The IMO understands there may be a European Court of Justice case taken against Ireland. I ask the panel to elaborate on this point. Is there a certainty that something is going to have to be done and perhaps this is the lever needed?
Sandra McLellan (Cork East, Sinn Fein)
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I thank the delegates for their attendance. A dangerous and illegal number of hours are being worked. Not only does this affect the mental health and well-being of the doctors, but it could also affect the care of patients. Health and safety are very important in all aspects of work. However, they seem to be blatantly disregarded in the health service. Should patients have confidence in doctors or the health service if they know doctors have just worked 72 hours without a break and are performing procedures on them? I do not understand why rosters cannot be shorter. I understand a person may be rostered for a certain period of time and that shifts may overrun. In the manufacturing sector in which workers also do shift work, nobody has to work three days straight, but people's lives are at risk in the case of NCHDs.
Ms Shirley Coulter:
I will deal with the questions from Deputies Mattie McGrath and Sandra McLellan on the point that this form of rostering does not occur in other industries. The key point in our opening submission is that there is no sanction or accountability; therefore, it can happen, day after day. One may ask whether things will change when there is an adverse outcome. There probably have been hundreds of adverse outcomes which, directly or indirectly, may have resulted from doctors working long hours and having to make life or death decisions when extremely tired and exhausted. "Prime Time" broadcast a good programme a number of weeks ago which featured a number of doctors who very bravely spoke out about their own personal experiences and the outcomes when they were fatigued. In answer to the Deputies' questions, there is a lack of sanction or accountability.
On the European Court of Justice case, this may be a question better asked of the HSE in the later session. The IMO received written correspondence from the HSE enclosing the standards. The information was contained in one line, that the European Court of Justice may be taking a case against Ireland. That was the only detail provided of what was potentially a massive and extremely costly case for the country. It was just one line in a lengthy document sent to us.
I will address the questions from Deputy Mary Mitchell O'Connor and Senator Colm Burke which are related. I thank Senator Colm Burke for his continued interest in NCHD issues. We have been in regular contact in the intervening period since our last meeting and his support is much appreciated by NCHDs.
The questions about the position of doctors whose contracts are due to expire are possibly best asked of the HSE. A new recruitment drive in Pakistan was mentioned. It is my understanding from the HSE that a form of exchange process is being planned as part of which very senior specialist trainees from Pakistan will come to Ireland on a two year rotational basis and then return to their training schemes. We do not have the details.
On the question about the numbers of doctors leaving after July, this will not be clear until the interview process is complete. Interviews remain to be conducted for posts around the country and this process is in train. The HSE will not have an indication until a little later as to the number of vacancies available from July. The IMO has always called for contingency planning because it has become evident, unfortunately, for the past few years, that there have been significant NCHD vacancies.
Jerry Buttimer (Cork South Central, Fine Gael)
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Has this contingency planning begun?
Jerry Buttimer (Cork South Central, Fine Gael)
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On the basis of the questions about recruitment and career planning, is Ms Coulter saying the HSE is doing nothing to alleviate the problem? Is it making it worse?
Jerry Buttimer (Cork South Central, Fine Gael)
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Will there be a similar outcome in July?
Ms Shirley Coulter:
From what we are hearing, there is certainly the potential for this to be the case. Another very significant issue for this year's medical graduates is that there are not sufficient intern places this year for the number of graduates. This is a very serious concern which the IMO has raised.
Jerry Buttimer (Cork South Central, Fine Gael)
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What about career progression?
Ms Shirley Coulter:
The Deputy concerned asked about the WHO guidelines and career progression. The guidelines on ethical recruitment from developing countries have been adopted by the HSE. They state medical staff recruited from developing countries must be provided with a certain level of training rather than simply being used to provide a service, which seems to be the case in Ireland. They further state further medical training in the developing country should be supported by the recruiting country. It is questionable whether the HSE is applying the guidelines in this case.
On the issue of career progression, Deputy Mary Mitchell O'Connor was referring to a piece in our previous submission about matching the numbers of NCHDs with specialist posts. There needs to be an increase in the number of specialist consultant and general practitioner posts. There is a disconnect between the number of NCHDs in training who will complete training and the number of specialist posts available for them.
Dr. Mark Murphy:
I echo what Ms Coulter said. In the view of many of my colleagues who work all over the country, the treatment of non-EU doctors was wholeheartedly unethical. They were treated appallingly. Even from the point of view of the optics, it is very bad treatment by an employer and symbolises what is wrong. It is tied with the career plan. I do not want to be too philosophical, but like all employees and others, NCHDs just want to have basic needs met, as per Maslow's hierarchy of needs. We want security; to know whether we will have a job in July and whether we can stay in Ireland. For example, we do not have access to water when working 72 hours, with the result that we do not pee. Honestly, these are the things about which we think. We face horrific things in our work.
Career planning is another issue. I refer to the UK or Australian system. A doctor is trained for two years at basic level and then progresses to a specialist training programme for six to 12 months. We want a training period of five years which would lead to consultant level in order that we could provide great care. We do not want to be middle grade NCHDs who are a permanent feature of the Irish system.
We want career planning in Ireland. How can we ensure it is introduced? We know what to do. It is a longer-term issue and we need to focus on it. We need more consultants. It is disgraceful that current medical students are not guaranteed employment in Ireland. We do not have enough consultants and we are having trouble recruiting NCHDs. However, interns will be unemployed because we and the other stakeholders are not involved in career planning. We need to tie up medical school graduates to a quick, expedient training course in order that they might become consultants and GPs.
3:00 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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Why is there no joined-up thinking between the colleges, management, the HSE and the IMO?
Dr. Mark Murphy:
There are processes and, in fairness, the postgraduate training bodies that are responsible for our training take on opinions from NCHDs and the latter are getting involved. It is not just the HSE. The training bodies need to stand over quicker training programmes that deliver better training. It must be stated that they have a responsibility to enforce appropriate training conditions for us. They are not really doing so at present.
Dr. Shane Considine:
I am hoping to start on a specialist training programme in the next year or two. It is extremely unsettling to be facing into a huge commitment of time, money and dedication without any real guarantee that there will be anything for me at the end of the programme. Efforts have been made to streamline training in Ireland. Credit must be given to some of the training bodies such as the College of Anaesthetists of Ireland and the Faculty of Radiologists at the Royal College of Surgeons. The Royal College of Surgeons has actually changed its training schemes in the current year so that they take the form of a run-through model. It is also planning to align the number of trainees it takes on with the projected number of consultant posts and also with the specific specialties where they are needed. Some credit is due for that but for the vast majority of us who are still in the system, or in all other specialties, there is a definite uncertainty as to where we will go at the end of our long training.
Deputy Ó Caoláin suggested that adverse events may occur. I suggest that such events happen every day. What we often think of are errors lead to patient harm. These things do happen. I refer to medication errors, inappropriate prescribing and incorrect doses being given. What we do not hear so much about are the adverse events which befall those who are delivering the care. We do not hear about the doctors involved in car accidents when they are driving home following 24, 36 or 72 hour call periods. We do not hear about those who receive needle-stick injuries following these long work periods. We have only begun to hear about the mental health issues that arise, such as depression, anxiety and, in some cases suicide. Obviously, all of those cannot wholly be attributed to our working conditions but those conditions certainly do not help. Adverse events occur all the time and that is something of which we must be wary.
Dr. Grainne O'Kane:
Career pathways are key for trainees in Ireland. I have been qualified for five years and I have obtained entry to a specialist registrar programme. However, I have also worked in Australia. Some 15 of those with whom I qualified left Ireland and five are still in Australia. Fundamentally, both the service and one's career pathway in that country are much better outlined. To be blunt, working conditions are a great deal better and there is much more focus on training. As doctors, we want to train and to provide the best possible care for our patients in the best possible conditions. That is why, ultimately, Irish graduates are leaving the country.
Regina Doherty (Meath East, Fine Gael)
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I have been very quiet during proceedings but that is not because I do not have questions. All my questions are for the next shower.
Jerry Buttimer (Cork South Central, Fine Gael)
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Will the Deputy please use parliamentary language?
Regina Doherty (Meath East, Fine Gael)
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I apologise. What I said sounds terrible.
Jerry Buttimer (Cork South Central, Fine Gael)
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Will the Deputy withdraw the remark?
Regina Doherty (Meath East, Fine Gael)
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I withdraw it. I meant to refer to the next group of witnesses.
I do not think there is anyone present who does not completely empathise with everything our guests have stated. It cannot simply be the case that those in authority are treating our guests as badly as they do because they can and because there are no sanctions. I could go into my office tomorrow and be mean to my staff just because I can do so. There must be other fundamental reasons rosters have not been changed, why a fobbing system has not been introduced and why the negative environment in which our guests are obliged to work has not been addressed. I will not even mention the complete lack of both progression and a defined career path. All these are genuine issues and they must be addressed. Whose fault is it that someone is obliged to work 72 hours and how can that be justified without those in authority having attempted to make changes - which perhaps did not work - in the past? I find it difficult to believe that in the years since Senator Crown was a trainee doctor, the environment has not changed and that this is because no one has attempted to change it.
Catherine Byrne (Dublin South Central, Fine Gael)
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I have listened with great interest. There are many at fault here. Part of the problem is that this has been allowed to go on for 30 or 40 years. I must inform Dr. Murphy that no one leaving college at present is guaranteed a job. Whether they are studying in the areas of medicine, business, child care or whatever, no one is guaranteed a job.
It all comes down to a duty of care. Regardless of whether one is a politician, a doctor, a street sweeper or a bin collector, one has a duty of care in the context of one's profession. The duty of care in this instance does not lie with the Minister, Deputy Reilly. I seldom disagree with Deputy Ó Caoláin but I must do so in the context of what he said about the Minister. The duty of care in this instance is with the HSE. Those who represent that body must be question with regard to how this situation has been allowed to obtain for so long.
I did not come here to be lectured by anybody. I am not referring to our guests but rather to others at this table who can make accusations and then leave. I take my job as a politician very seriously. I work long hours and I am rearing a family in the meantime. When I go home, I cook, do the washing and everything else. Everyone present is a professional. We all come from different backgrounds and we all chose different careers.
I reiterate that the problem in respect of this matter relates to the HSE's duty of care. The CEOs and others at the top who run our hospitals must also bear some responsibility. The blame cannot just be laid at the feet of various Ministers. I agree that the problem has not just arisen in the two years since Deputy Reilly became Minister. It has been ignored by successive Governments. However, the HSE has huge responsibility in respect of this matter and it needs to realise that fact.
Ms Shirley Coulter:
With regard to Deputy Regina Doherty's point to the effect that it cannot be as straightforward as stating that nothing is changing because there is no sanction or accountability, what is happening is endemic in the system. It has been the way things are for so long. However, this does not mean that it should continue to be the way. It is certainly because of the lack of accountability or sanction that things are not changing. At the end of the day, the interests of hospitals relate to throughput of patients and for patients to be looked after and discharged. That is continuing to occur. As long as this is the case and as long as hospitals remain within budget, those in authority in the hospitals have, in their view, realised their duty of care to patients. They are, however, missing the point when it comes to their duty of care to their staff and to the doctors who deliver the care in question. They are also missing the vital point that in the context of patient care, it is not safe to have tired doctors. As Dr. Considine stated, these adverse events are happening but they are not being openly and publicly attributed to people's working hours. They are happening and perhaps it is time to stand up. This is not about pointing figures or blaming individuals but everyone must be made aware of the implications of long working hours in respect of patient care. It is also time there was accountability for this at hospital level.
Dr. Mark Murphy:
Everyone agrees that this is not right. We all know that and we are in agreement with regard to what is the problem. We also kind of agree with what are the solutions but no one is ensuring that these solutions are put in place. It is the culture that exists and we need to change it. We can do so.
I do not wish to sound pious but I must inform Deputy Regina Doherty that NCHDs are very vulnerable. I completely appreciate the point made by Deputy Catherine Byrne. We see the impact of austerity and we also see the vulnerable, marginalised and those who are victims in society in our hospitals.
We are in a wonderful profession and we appreciate that, but nevertheless there are wrongs in the system and they need to be dealt with. Non-consultant hospital doctors are very vulnerable. We often rotate every three to six months. We find it difficult to rock the boat as we are looking after our careers. If one can think back on one's previous employment and if one built up five or ten years of loyalty and relationships, one can change systems, but in our case we move around very often. Dr. O'Kane has done fantastic work in two hospitals and that was achieved in only one year. Imagine what could happen if NCHDs were in positions for longer. We are vulnerable and that is part of the problem.
There are many long-term considerations, such as those provided in the Hanly report, that need to happen to make the health services better. They would make us compliant with the European working time directive and reform the hospital services for the benefit of the patients. This year we need to get some tangible solutions. In focusing on working roles and the way we work, it is not a question of dumping our roles onto other professionals but about the clever application of what constitutes the best use of resources in terms of us, allied health professionals, phlebotomy, what we do, IT and other considerations. In respect of the two issues of our roles and rostering, I hope the committee tries to instill some accountability for those with the HSE later.
3:10 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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Before we suspend at the conclusion of this part of our meeting, I thank most sincerely Ms Shirley Coulter, and the three doctors, Dr. Mark Murphy, Dr. Shane Considine and Dr. Grainne O'Kane, in particular, for their presence here today, the articulation of their viewpoints and their willingness to engage with the committee. From a committee point of view, we are concerned about this issue. This is our second meeting on it and we have also issued a report on it. It is an issue about which we are vigilant and in the second half of our meeting we will engage with the HSE. I again thank the witnesses for coming in.
Colm Burke (Fine Gael)
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I would like to make a brief comment. I thought we had faced the crisis in 2011 and that we were dealing with this issue but from what the witnesses have told us, it appears that nothing has changed in recent years.
Jerry Buttimer (Cork South Central, Fine Gael)
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We will get the second half of the story from our engagement with the HSE and we can discuss that point, which is a fair one, in the summation later.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I want to turn the Chairman's comment around - no harm to the doctors - that this was the most competent presentation I have heard here in a long time and I thank the witnesses for that.
Jerry Buttimer (Cork South Central, Fine Gael)
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Go raibh míle maith agaibh. Tá an comhchoiste ar fionraí go dtí 3.30 p.m. We will suspend until 3.30 p.m.
3:15 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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Táimid i seisiún poiblí. Inniu, tá an fo-choiste anseo chun díospóireacht a dhéanamh ar choinníollacha fostaíochta dochtúirí neamh-chomhairleacha ospidéil. Ba mhaith liom fíor fáilte a ghabháil le baill Fheidhmeannacht na Seirbhíse Sláinte. I welcome to the second part of the meeting Ms Laverne McGuinness, Mr. Barry O'Brien and Professor Eilis McGovern, and also Mr. Ian Carter and Mr. Andrew Condon. We are discussing the employment conditions of non-consultant hospital doctors. We had an informative and challenging meeting earlier with representatives of the IMO who made a strong presentation to the committee. I thank most sincerely Ms Laverne McGuinness, chief operations officer of the HSE, Mr. Barry O'Brien, national director of human resources, and Prof. Eilis McGovern, national programme director for medical training, for attending this afternoon.
Before we commence I remind members and witnesses that witnesses are protected by absolute privilege in respect of the evidence they give this committee. However, if a witness is directed by the committee to cease giving evidence on a particular matter and the witness continues to so do, the witness is entitled thereafter only to qualified privilege in respect of his or her evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.
I apologise for the poor attendance. Some members have been called to another meeting. We have a list of apologies. I also welcome Mr. Ian Carter and Mr. Andrew Condon from the HSE who are seated behind me. I invite Ms McGuinness to make her opening statement.
Ms Laverne McGuinness:
I wish the Chairman and members of the committee a good afternoon. I thank them for the invitation to attend the committee meeting this afternoon. I am joined by my colleagues whom the Chairman has introduced: Mr. Barry O’Brien, national director of human resources, HR; Professor Eilis McGovern, director of medical education and training; Mr. Ian Carter, national lead on European working time directive programme; and Mr. Andrew Condon, general manager, human resources.
Jerry Buttimer (Cork South Central, Fine Gael)
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The other gentlemen are welcome to sit in the front if they wish. Rather than having them hide behind their colleagues we wish to show respect to them given the effort they have made to attend the meeting. I thank them for attending.
Ms Laverne McGuinness:
Non-consultant doctors play a very important and fundamental role in the provision of services in our hospitals. The health service has been attempting to deal with this complex issue of the European working time directive, EWTD, for a number of years. The health service is working closely with individual hospitals, the colleges, our quality and patient safety directorate and human resources directorate to implement the EWTD. We have undertaken a range of actions to address this problem and have a range of further measures in place which I will refer to later.
The HSE engages with non-consultant hospital doctors, NCHDs, on two levels, first as employer and second as a trainer. The HSE provides significant financial support towards NCHD training. Taking this into account, I will focus on three areas in my opening statement, as follows: NCHD recruitment; the European working time directive; and medical education and training. The current NCHD workforce comprises approximately 4,910 NCHDs, including 570 interns, 1,812 senior house officers, SHOs, 1,620 registrars and 908 specialist-senior registrars. Of the 4,910, 80% hold structured training posts, while 20% of NCHDs hold service posts. In recent years the HSE has increased the proportion of NCHDs in formal training schemes from less than 40% to approximately 80%, increased the number of specialist registrar posts by 60% and this year will further increase intern posts from 570 to 639.
There are two types of NCHD posts – training posts and service posts. A total of 81% of NCHDs are recruited by postgraduate training bodies for placement in training posts in hospitals or health agencies. The HSE recruits approximately 15% of NCHDs – all of whom are recruited to service posts. HSE-funded agencies recruit the remaining 4% of NCHDs to service posts. Particular hospitals and specialties have experienced difficulties filling NCHD posts over the past number of years. Addressing this issue has been a priority for the HSE and has included a number of recruitment programmes internationally, including the recent one to India. NCHDs are recruited twice a year – in January and July – to accommodate training rotations. To ensure the maximum number of posts are filled, a number of separate recruitment processes are currently under way in preparation for July 2013. I have set them out in my statement. They include recruitment in South Africa.
The EWTD places strict requirements on the HSE. I have set them out in my presentation. A specific area on which we are not fully compliant is to work no more than 48 hours a week, on average. I will address the issue later. Full implementation of the European working time directive poses very significant challenges for the health service and has been the subject of a series of reports over the past decade. I have set out the details of the various reports in my statement. In essence, the reports identify six key measures that are required to support the implementation of the European working time directive. They include: new work patterns for NCHDs to include 5/7 working and shorter shift periods; reduction of tiered on-call - where interns, senior house officers, registrars and senior or specialist registrars and consultants participate in a tiered on-call system; cross-cover arrangements at senior house officer and registrar levels; changes to delivery of medical education and training; the introduction of a consultant-provided service; and reconfiguration of acute hospital services. These reports concluded that the key drivers of NCHD hours are service needs, how hospitals are configured internally and what services each hospital provides.
While the draft Smaller Hospital Framework, which is currently in development and set for roll-out in the coming months, and the wider move to hospital groups will facilitate reconfiguration, it is important to note that in hospitals where the workload does not exist to support non-consultant hospital doctor, NCHD, training or increased numbers of consultants, European working time directive, EWTD, compliance can only be achieved by changing the type of services delivered and the times during which services are delivered. The decision on the NCHD rosters that are put in place to maintain services is best made at local level by consultants, clinical directors and service and hospital managers.
Regarding compliance, the health service has almost complete compliance with weekly and fortnightly rest, and significant compliance with breaks. However, there is limited compliance with daily rest and the 48 hour average working week. In this regard, many doctors do not receive adequate daily rest and many more work in excess of the average 48 hour working week.
While substantial progress towards EWTD compliance has been made in some sites, including some of our large hospitals such as Galway University Hospital and St Vincent's University Hospital, our most significant challenges are in small to medium sized hospitals such as Portlaoise hospital or Tralee hospital, with low numbers of doctors on rotas in surgery, anaesthetics, paediatrics and obstetrics. In larger sites, challenges arise in complex sub-specialty areas.
Regarding the implementation of the European working time directive, in 2009, agreement was reached on the introduction of new rostering arrangements. Since then, significant progress has been made on EWTD implementation. However, we still have much more to do, which I will address later. The following has been delivered: the introduction of the new work patterns for NCHDs, following agreement on a new NCHD contract in 2010; the reduction of tiered on-call; use of cross cover arrangements within general medicine and general surgery; changes to the delivery of medical education and training. As of January 2013, 80% of NCHDs are in training posts as compared to 40% in 2007; the number of consultant posts has increased significantly by 33% since 2005. We have gone from 1,947 in 2005 to 2,593 in 2013; since September 2012, employers can roster consultants over the full five out of seven period, which will help reduce NCHD hours; and in January of this year, the national EWTD working group adopted a set of national standards for reducing NCHD hours. Implementation of these standards will ensure significant progress towards EWTD compliance.
This year, Ireland has indicated to the European Commission that it is committed to full implementation of the EWTD for NCHDs by the end of 2014. To progress this, the Health Service Executive, HSE, has established a national implementation groupchaired by Mr. Ian Carter, who is present, to drive maximum possible EWTD compliance within each hospital. Each hospital-agency is currently preparing an action plan which identifies the steps to be taken to implement the national standards, other actions that will reduce NCHD hours, and related timescales and accountability. First drafts are currently being returned and collated.
There is a particular focus on ensuring that no NCHD has to work more than 24 continuous hours on site after 1June 2013, and that no NCHD works more than 68 hours in a week by 31March of this year.
A key issue is the extent to which part of the current NCHD workload should be more appropriately delivered by other staff. As part of that exercise the HSE is requiring hospitals to identify specific non-medical staff in each hospital to lead delivery of phlebotomy, cannulation and catheterisation services, and transport of files, clinical materials etc.
During the 2013-2014 period, the HSE is engaging with the Forum of Postgraduate Medical Training Bodies and the Irish Medical Organisation to ensure that NCHDs input into the implementation process at national level.
Medical education and training is a priority for the HSE. To ensure it is delivered appropriately, the HSE has formal agreements in place with the recognised postgraduate medical training bodies in Ireland regarding the provision of specialist medical education and training to the junior doctor cohort in Ireland. These agreements, inter alia, define the number of doctors to be trained by each training body both by year of training and by specialty. These numbers are defined by the HSE following consultation with the training bodies and consideration of current and future workforce requirements for qualified specialists.
The HSE invests approximately €14 million in such programmes each year. This means that, among others, the HSE directly funds the cost of basic specialist training and higher specialist training programmes; increased general practitioner training numbers from 120 to 157 per year in line with GP workforce requirements; in 2013, the HSE has increased the number of intern places from 570 to 639 within existing budgets and employment ceilings; and the HSE has implemented two scholarships programmes specifically targeting NCHDs in their latter stages of training. That concludes my opening statement and my colleagues and I will take members' questions.
3:25 pm
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join in the welcome to all the representatives of the HSE. This is the second part of a two-part meeting. The opening session heard very strong representations from representatives of the non-consultant hospital doctors. Some 18 months after the last time we met them in October 2011, what they had to record here before the committee today is hugely worrying.
It is at least two years or perhaps longer since we adopted emergency legislation to facilitate the recruitment of NCHDs externally to meet a very serious crisis then presenting. I would like the witness to indicate the position currently regarding the cohort of NCHDs within the system and if we are looking at a further period of difficulty leading into July of this year and the two year anniversary of that initial recruitment in India and Pakistan.
Regarding the points made by the NCHD voices earlier, it is important to share those with the witnesses, if they have not already picked up on what they put on the record today. They have indicated to us that since our last meeting with them in October 2011 little, if any, progress has been made across the list of areas of concern they shared with us at that time. They have spoken of dangerous and illegal hours. They have indicated that patient care is being jeopardised - I emphasise "is being jeopardised" - and that "an accident will happen as a result of this working regime and it will have serious and perhaps even fatal consequences". The seriousness of what they have shared with us, and the way they have followed it through in their support of subsequent commentary, has left the members of this committee fairly certain that this is a serious problem, despite all that Ms McGuinness has put on the record in her contribution. We cannot fail to ignore their further comment about "consistent and dangerous flouting of the law every day in hospitals around the country".
I noted Ms McGuinness in her contribution spoke in statistical terms quoting averages in a number of instances, but the reality for many NCHDs is very different from the ostensible average position. The reality is as grave as the voices we have already heard have indicated to us. Ms McGuinness mentioned an average 48 hours. They spoke earlier about a HSE claim in regard to 54 hours, but the truth is that we are talking about something of the order of 65 hours per week in many instances, and in some cases far exceeding that.
They outlined what is required to address the situation immediately as against what we have all acknowledged previously was required in the medium to longer term, that is, a clearly defined career path opportunity with greater numbers of consultant posts to properly accommodate this number of committed young doctors, something which all of us in this committee support.
They made two key proposals on what is required now, namely, to introduce a 24-hour on-site shift and to change the roles. Many of us, from our respective experiences as patients, would know of incidents in which highly trained nursing staff would have been well capable of carrying out many of the functions that non-consultant hospital doctors currently carry out in a number of hospitals. There is a neat fit with the case presented by the INMO regarding several of these responsibilities. I refer to the removal of inappropriate tasks from the list of functions and responsibilities currently overburdening non-consultant hospital doctors in many hospitals.
We have explored further where the signal came from in respect of the EU working time directive. It may have come from the HSE that the European Court of Justice may well be considering taking a case against Ireland for its failure to adhere to the directive. Despite the progress being made and the signalled intent to cover much, if not all, of what is required by 2014, it strikes members of this committee that it is inexcusable in 2013 that circumstances remain as they are. I am concerned not only about the interest of the doctors, their health and ability to carry out their tasks and make professional judgments but also about the interest of members of the public, who depend on a quality service that puts their safety first.
3:35 pm
Colm Burke (Fine Gael)
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I thank the witnesses for attending. It is a very difficult task to organise the entire hospital structure and ensure there is an adequate number of doctors. Let me refer briefly to structured training. On the last occasion on which we had a quarterly meeting, I asked for a breakdown of the number of doctors on six-month contracts, 12-month contracts, two-year contracts and three-year contracts but I could not get an answer. If 80% are on structured training, what is the nature of that training? Is it still a case of six-month or 12-month contracts?
I accept that, with the reconfiguration and restructuring of hospital groups, we will be better off and able to do very much what is being done in the United Kingdom, where one might get a three-year contract, albeit a contract that might cover three or four hospitals. I fully understand that.
With regard to the doctors we brought in from Pakistan and India in 2011, I understand there are more than 230. I understand these doctors will not be offered unemployment once their two-year contracts end. I have been told about a case in a particular hospital where there are five or six registrars in anaesthetics. One is an agency doctor, rather than a locum, and is therefore being paid at the top rate. Although the doctor was offered a six-month contract, he would not take it because he came in under an agency. A doctor from Pakistan on a two-year contract would be suited to taking up the registrar post but if one applies the rules the witnesses are talking about applying, that doctor cannot be offered the post. The hospital has had difficulty filling posts in this particular area. What do we do in the circumstances? Do we still continue to pay double for the agency doctor as opposed to offering a job to someone who is, in the hospital's eyes, competent and who has two years' experience?
The next issue I wish to raise in regard to recruitment from Pakistan is mentioned in the report. I am a little concerned about it. On the last occasion, under the supervised division people had to sit exams. Under the new arrangement – this pertains to my question on doctors who have two years' experience – it is proposed to bring in people who will not be required to sit an exam before they start. I am open to correction but need clarification on it. Furthermore, the candidates will have no experience of having worked outside their own countries. Therefore, we are starting an entirely new process. Are we losing out as a consequence?
The final issue I wish to raise is the major concern of a number of hospitals, smaller ones in particular. In the past, they were able to carry out their own recruitment, and they were able to do so very well. They did not have a problem because they were taking recommendations from colleagues and were able take on doctors to fill the vacancies as they arose. Under the central recruitment system, the small hospitals find they are not necessarily getting doctors of the standard that they used to get. The knock-on effect is that, where consultants are on a one-in-two or one-in-three rota, nursing staff lose confidence. This is because the junior doctors are under a lot of pressure and are tired. Nurses are contacting the consultants on the one-in-two and one-in three rotas and it is now proving very difficult to provide a safe system in the hospitals both in regard to junior doctors and those at consultant level. While centralised recruitment is great in theory, has there been consultation with the smaller hospitals to try to surmount the difficulties they must deal with the present?
In obstetrics and gynaecology in Cavan, there are five registrar posts but only two are filled. Consequently, there are three vacancies. There is a problem in Limerick with regard to filling vacancies, and Tralee also has a problem. This was mentioned in the report. Could this be clarified?
Regina Doherty (Meath East, Fine Gael)
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I thank all the witnesses for attending this afternoon. The presentations of the previous witnesses and Ms McGuinness are chalk and cheese. One would swear we were talking about two completely different countries or two different topics. I do not know how to say this without saying something inappropriate but it is obvious that one presentation is not right. Both could not be right. A group of young doctors and their representatives told us that conditions are absolutely appalling and that there is absolutely no engagement with the employer. Obviously, there is engagement because some changes have been made over recent years. I appreciate that not as many changes have been made as the employer would wish. What is the nature of the gap that is causing a considerable difficulty with communications? Is it just standard industrial relations such that both sides are fighting their corner and not willing to give an inch? Could this be explained? How could circumstances be improved?
Given all the improvements that Ms McGuinness has just detailed, who is responsible for the person who earned €150,000 in overtime last year? How did this arise? How could any employer be happy with that scenario? As a potential patient, I query the position of the HSE, as employer, with regard to the very great concerns the doctors raised with us and mentioned in the media and on Twitter in recent weeks, not only with regard to their physical and mental well-being but also with regard to the patient they must treat at the end of a 24-hour, 48-hour or 72-hour shift? How concerned is the HSE about that as an employer and provider of services to the patient? What immediate plans will we see over the course of the next six to 12 months to alleviate the problem?
3:45 pm
Mattie McGrath (Tipperary South, Independent)
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I apologise for being obliged to leave the meeting to attend Leaders' Questions in the Dáil. I also welcome the invited guests.
Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy is more than welcome to stay here with us.
Mattie McGrath (Tipperary South, Independent)
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I appreciate that, but beidh lá eile. I welcome the delegates and thank them for their attendance. However, as other members have noted, it is a different world from that described by the previous representatives and from what members know they are working in. Anyone who visits hospitals, has relatives or been sick is aware of the real position. I am a small employer - I had ten employees but now have six - and governed by legislation, as is every other employer. Health and safety matters such as hazard analysis and critical control point, HAACP, systems, the working time directive and working hours take precedence in any workplace, but no issue is as serious as health. I have to hand the HSE's report which differs completely from that of the previous delegates. It contains jargon and nice-speak and makes good use of language and fancy acronyms. At one time matrons ran hospitals, but the HSE now employs many people who were not there previously. There are ward managers, bed managers, time managers and every other kind of manager. That is the problem.
Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy might be more respectful of the delegates.
Mattie McGrath (Tipperary South, Independent)
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I am sorry-----
Jerry Buttimer (Cork South Central, Fine Gael)
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To be fair, the Deputy might show some respect to the delegates.
Mattie McGrath (Tipperary South, Independent)
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Yes, I will. I am just saying-----
Jerry Buttimer (Cork South Central, Fine Gael)
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Some balance is all I suggest.
Mattie McGrath (Tipperary South, Independent)
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I am trying to strike a balance, but I encounter this problem in my constituency on a daily basis. I had meetings with representatives of the HSE on Sunday and Monday. There is a disconnect in the HSE between those who deliver front-line services and management. Is there workforce planning because if there is, it is very poor? Members heard earlier that the HSE had a national working group, but it has only had one meeting with the previous delegates. We have heard that there has been no proper engagement or no medical engagement. This happens all the time with the HSE and it dates back to the time of its establishment when this buffer was put in place by a Government of which I accept I was a supporter. Members had fought for years because they were not getting replies from the Minister who had no responsibility for the HSE. It is a fact that the HSE appears to be a law unto itself and that it operates outside the law in many areas with regard to health and safety issues.
Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy is incorrect because if one takes the HSE plan unfurled last week, there was consultation this week.
Mattie McGrath (Tipperary South, Independent)
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Yes, after it was unfurled.
Jerry Buttimer (Cork South Central, Fine Gael)
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I am sorry, Deputy, but this is a House of Parliament and we are Members of the Oireachtas.
Mattie McGrath (Tipperary South, Independent)
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Yes.
Jerry Buttimer (Cork South Central, Fine Gael)
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The language we use and the way we say things-----
Mattie McGrath (Tipperary South, Independent)
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I understand that totally.
Jerry Buttimer (Cork South Central, Fine Gael)
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Will the Deputy, please, be considerate to those who are present?
Mattie McGrath (Tipperary South, Independent)
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The Chairman can mention the plan unfurled last week, as he did-----
Jerry Buttimer (Cork South Central, Fine Gael)
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Will the Deputy, please, be considerate to those who are in attendance today-----
Mattie McGrath (Tipperary South, Independent)
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Yes, I am being considerate to them.
Jerry Buttimer (Cork South Central, Fine Gael)
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-----and try not to engage in cheap headline-making?
Mattie McGrath (Tipperary South, Independent)
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I do not wish to so engage, but I am stating a fact. The Chairman mentioned the plan unfurled nationwide last week with millions-----
Jerry Buttimer (Cork South Central, Fine Gael)
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All I am saying is that the Deputy can make his remarks without being personal.
Mattie McGrath (Tipperary South, Independent)
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It included cuts of millions of euro and involves 3,000 or 4,000 fewer staff.
Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Caoimhghín Ó Caoláin made this point without being personal.
Mattie McGrath (Tipperary South, Independent)
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I am not being personal. I am challenging a system that has failed and is failing its employees. As for the seriousness of this issue, this does not pertain to the position of ordinary employees but affects health care. In the aforementioned huge system there is a huge disconnect. Plans are unfurled and one must dig into them to find out the small items of concern to oneself. They are delivered with huge volumes of paper and there is no consultation. Clearly, as stated again at this meeting, there is no consultation with stakeholders or those on the front line. There is no proper workforce planning, except for endless reports, while health and safety issues are being ignored. It is criminal.
Sandra McLellan (Cork East, Sinn Fein)
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I thank the delegates for their attendance but as the previous speaker noted, the two reports are very different. It appears, from members' beliefs or what they have heard in recent years, that a lot of non-consultant hospital doctors, NCHDs, are working a highly dangerous and illegal number of hours. While health and safety are very important in all aspects of life, they appear to be disregarded to a great extent within the health service. I will repeat the question I asked earlier: if I was a patient and thought someone had worked for 48 or 72 hours without leaving the hospital, would I have confidence in him or her in carrying out a procedure on me? I would not. It appears as though rosters are a huge issue and could be improved a lot, even with a little consultation with non-consultant hospital doctors. It also appears as though career paths are better laid out in other countries than the manner in which they are structured here. Is it true there that are not enough medical places for interns this summer?
Catherine Byrne (Dublin South Central, Fine Gael)
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First, I thank Ms Laverne McGuinness and the other delegates for their attendance. I apologise for being obliged to leave the meeting for a while.
While I did not hear Ms McGuinness's presentation, it states, "In 2009, agreement was reached on the introduction of new rostering arrangements. Since then, significant progress has been made." However, there still is much to do and Ms McGuinness indicated she would address this point later. I cannot speak for anyone else in the room, but when I attend hospital, either personally or with family members, the first person I always meet is the receptionist, while the second is usually the nurse. The third is usually a young man or girl in his or her early 20s. I sometimes feel very sorry for them because they look as though they have been through the mill from the perspective of their own health, having been up all night or the night before because of work. Earlier members were discussing duty of care in the workplace and its importance for persons being treated and, in particular, the person who is treating my family members or those of Ms McGuinness. Can Ms McGuinness and the HSE stand over the appropriate care being given by young doctors in accident and emergency units? If so, what is the reason for the statements from the previous delegates? While I acknowledge I have only read Ms McGuinness's statement and did not hear her saying it, how can there be such a difference between her statement and those of the previous delegates? I believe everyone has made the same point in this regard. To revert to my first point, with whom was the agreement negotiated? According to the statement, "In 2009, agreement was reached...". With whom was it reached because obviously the preceding delegates do not agree with this line? Can the HSE stand over the appropriate services being provided by young people who are in the line of fire in every accident and emergency unit nationwide?
Jerry Buttimer (Cork South Central, Fine Gael)
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Ms McGuinness might note it is fair to state the two presentations are like day and night. Members heard a different viewpoint from the delegates who preceded the HSE representatives from that provided by Ms McGuinness. Consequently, they will be interested to hear her responses.
Ms Laverne McGuinness:
I thank the Chairman and members. I will collate some of the responses because some of the questions were similar.
As for the difference between the two presentations, I have not had the opportunity to review the Irish Medical Organisation's statement, but what I have presented is factually accurate. I draw members' attention, because this issue is of significant interest, to the point made on page 4 of the statement that "In this regard, many doctors do not receive adequate daily rest and many more work in excess of the average 48 hour working week". The aforementioned figure of 48 hours is the requirement under the European working time directive and I have stated the HSE has not delivered or achieved it. Now that we have the standards which were only concluded in January, we have put together an implementation group to strive towards the 48 hour week
Jerry Buttimer (Cork South Central, Fine Gael)
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Was there consultation with all stakeholders in arriving at the standards?
Ms Laverne McGuinness:
There was wide consultation on the standards with the colleges, forums and medical bodies on their development. The standards have been submitted to the European Commission and are the standards against which we are measuring ourselves. Consequently, we have acknowledged that the HSE is not in compliance with the European working time directive with regard to the figure of 48 hours. We have set out a reason this is the case. A number of measures must be taken to get there and a number of steps are in play that will help us. One is the reconfiguration of the hospitals. The smaller hospitals framework is due to be published in the coming weeks and it will allow us to ensure services will be provided in the appropriate hospital. In turn, that will allow us to free up some of the time of doctors to work on other sites in order that we will not have the same requirement in respect of hours. This pertains to hours of attendance, hours of opening, etc.
As for the figure of 54 hours to which Deputy Caoimhghín Ó Caoláin referred but to which I did not make reference in my statement, that is an average. I am conscious that it was based on manual returns and individual audits in the last study we carried out. Based on the information provided for us by the hospitals, the figure is 54 hours, although many doctors work in excess of that figure.
As part of what we are implementing, the first target is to ensure that by 31 March the weekly working hours for doctors are no more than 68, and this will be reduced. It depends on the rota that is currently there, which is the one-in-three rota. That is the target we have set. Each hospital is currently preparing its plans and implementing them to be on track for that. That is the group that Mr. Ian Carter is chairing for us.
3:55 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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Is that attainable by 31 March?
Ms Laverne McGuinness:
That is what is required by 31 March. That is what we have said has to be achieved by 31 March. In order to put that in place there was some discussion about unrostered overtime. Some of our hospitals have issued instructions that unrostered overtime must be completed on a separate form. The reason is that it is not sufficient for a doctor to say that he or she did unrostered overtime because the hospital was busy. More specifics are required. In fact, clinical directors are engaging with non-consultant hospital doctors ensure that once their rostered work is finished they go home, unless an emergency requires them to be there, such as a cardiac arrest.
Jerry Buttimer (Cork South Central, Fine Gael)
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One of the doctors told us this afternoon that he could not leave if his patient had not been taken care of. Let us say, for argument's sake, that 5 o'clock was the curfew time. He said he could not leave at that time if a patient was in need of follow-up care.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Did Ms McGuinness say 68 hours?
Jerry Buttimer (Cork South Central, Fine Gael)
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It is on page 5 of the presentation.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Could I hear it again?
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Would we not all agree that that is absolutely unacceptable? Surely that is not a target.
Ms Laverne McGuinness:
What we are saying is that after 31 March, which is four weeks away, no doctor can be on 68 hours. The Deputy has mentioned that some doctors have received quite significant amounts of overtime payment, which is because they have been working. In some places, we have small hospitals. There are specific areas where the number of doctors that support rotas is quite small. Therefore, this needs to take place together with a reconfiguration of services. That is why one of the first issues were are addressing is number of hours worked per week. At other hospital sites it depends on the rota, so by 1 May, if there is a one-in-five rota, a doctor cannot work 60 hours. It goes right down by 1 June 2013, when the number of weekly working hours will be capped at 48. We are working through a programme of reduction - it cannot all happen overnight - based on our current configuration of services and how we are delivering. That is a programme of work that we have set out. I hope that answers the Deputy's question on averages.
The other question was about being on-site for more than 24 hours, which I have also referred to in page 5 of the statement. I have included that for the committee. No non-consultant hospital doctor will have to work more than 24 continuous hours on-site after 1 June 2013. It is at the bottom of page 5.
Jerry Buttimer (Cork South Central, Fine Gael)
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Is that attainable, given the presentations we had earlier today and given the anecdotal evidence that many of us have brought to the committee, not just today but previously? Will we see this happening?
Ms Laverne McGuinness:
This is the implementation plan. Mr. Ian Carter is the project manager who is heading up the group. We also have Dr. Colum Henry, our national clinical lead on this matter, and Professor Eilis McGovern, because part of this concerns the training of more non-consultant hospital doctors, which we are already doing this year. Mr. Andrew Condon is on the group also, as is Dr. Philip Crowley, who is our head of quality and risk. That is the group we have put together. Other stakeholders will also be brought in at various times. They will be working with each of the hospitals and with regional directors of operations to ensure compliance with this trajectory that we have set out.
Regina Doherty (Meath East, Fine Gael)
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The targets are great but what has Ms McGuinness done to be able to make this transition to 48-hour working weeks so quickly, by the end of June? What has changed?
Ms Laverne McGuinness:
We have put together the standards that now need to be implemented. Those standards were completed in January 2013. We are changing rosters and unrostered overtime. We are doing exactly what one of the Deputies said, because some of the tasks that are currently carried out by junior doctors do not necessarily need to be, including cannulations and catheterisations, as set out in our statement. Professor Eilis McGovern will speak about the training programme. There is also an engagement with clinical directors and consultants. Since 2005, the number of consultants has increased by 33%. That is the programme, and there will be challenges.
Jerry Buttimer (Cork South Central, Fine Gael)
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Are there more non-consultant hospital doctor posts?
Mr. Barry O'Brien:
We need to put some of the comments in perspective. While we have reduced the headcount by nearly 11,500 in the last five years, there have never been more doctors in training in the country. There have never been more consultants employed in our public health system. There has never been more money spent in that whole area. We have had positive discrimination in recruiting consultants and maintaining the numbers of non-consultant hospital doctors.
Colm Burke (Fine Gael)
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The Hanly report said there would be 3,600 consultants by 2012.
Jerry Buttimer (Cork South Central, Fine Gael)
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I will bring Senator Burke back in a second. Please let Mr. O'Brien finish first.
Mr. Barry O'Brien:
With respect and in the interests of accuracy, the Hanly report also said that we should halve the number of non-consultant hospital doctors in the same time, which we have not done at all. We have maintained the number.
A point was made about recruitment in local hospitals. It is important to stress that the HSE directly recruits only 15% of all non-consultant hospital doctors. We clearly told the committee that 60% are placed by colleges directly into training places. We recruit 15%, which are service posts. I can confirm for Senator Burke that 70% of that 15% are filled by local recruitment. All we have is a central applications office, not a central recruitment process. We get applicants and give them to the local hospitals which then interview them and proceed to make service-level appointments. That is how it works in that area. It is important to say that a significant manpower plan is in place with regard to giving effect to a consultant-delivered service.
Jerry Buttimer (Cork South Central, Fine Gael)
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In the context of our discussion, we were told that there was probably no plan B for recruitment if there is a shortage come July.
Professor Eilis McGovern:
I will answer Senator Burke's three questions that pertained to training. He asked about the duration of training programmes for the 80% of doctors who are in structured training. Interns get a one-year contract. Basic specialty training is either two or three years, depending on the specialty. Higher specialist training is between four and six years depending on the specialty. Other than those posts, the other 20% of posts that are not in training - around 1,000 - are non-training by definition or are sometimes referred to as service-grade posts. Those are invariably one-year contracts, often renewed.
Colm Burke (Fine Gael)
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The HSE still cannot provide a breakdown of how many junior doctors are on 12-month, two-year or three-year contracts. If it is as structured as claimed, why can we not get that breakdown?
Jerry Buttimer (Cork South Central, Fine Gael)
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That is okay.
Professor Eilis McGovern:
We know there are 570 interns. There are approximately 1,600 doctors in basic specialty training. They are either in two- or three-year programmes. There are approximately 900 doctors in higher specialist training, which ranges from four to six years. There is a fourth category of training called registrar training posts, which are one-year posts renewable for a second year. There are approximately 250 in those posts.
Jerry Buttimer (Cork South Central, Fine Gael)
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Professor McGovern might be able to furnish the committee with those figures.
Colm Burke (Fine Gael)
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I asked this question previously and did not get an answer to it.
Jerry Buttimer (Cork South Central, Fine Gael)
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We will get the answer this time.
4:05 pm
Professor Eilis McGovern:
The second question Senator Burke asked was about the supervised division doctors who came here two years ago and why they cannot have their posts renewed for a third year. He also gave an example of where there is a vacancy where someone who now has two years of experience could step into that post. We are bound by the Medical Council regulation, the wording of which is that no doctor may spend more than two years of aggregate time on the supervised division. There were approximately 290 doctors in total who came into the supervised division through the India-Pakistan initiative and the registration for the first group of those will be complete in September or October of this year. As that is a statutory instrument, there is not a facility for those doctors to remain on the supervised division. If they wish to remain in employment in the Irish health service, they must transfer to a different division. The options are the other divisions, namely, the specialist division, the trainee division or the general division. For most of them, the vast majority, the only option they have for various reasons is the general division.
The third question Senator Burke asked was about the Pakistan initiative that we are introducing in July of this year. This differs completely from the India-Pakistan recruitment initiative of two years ago. We felt that we have a tradition in Ireland of training doctors from low and middle income countries - it is not fair even to restrict it to that. We have a tradition of training doctors from overseas who come to Ireland. Irish doctors go overseas and they are overseas doctors when they are in America, Canada or wherever. It is a tradition within international health services. In Ireland, up until now we have had no structured way of doing that. Doctors come in a random way, usually singly, and they themselves are not happy with the experience that they get. There has been a HRB study done of a cohort of these doctors and they come to Ireland for the same reasons that Irish doctors go abroad, to get structured training and career progression, and they are not getting that here in Ireland. They tend to end up in the service grade posts where they are not getting structured training and they are not able to progress in their careers. We felt that a better way of training doctors from other countries, what we call international medical graduates, would be to do that in a structured way by developing partnerships with other countries' governments or government agencies. The HSE signed a memorandum of understanding with the College of Physicians and Surgeons of Pakistan in November 2011. Under that memorandum, we are carrying out a pilot programme where in July we hope to bring 60 trainees from the training programmes in Pakistan here for two years of structured training. At the end of that two years, they will return to Pakistan to complete their training and to add value to the health service there, which is analogous to our own doctors, who go abroad who, we hope, will come back to add value to the health system here in Ireland.
Jerry Buttimer (Cork South Central, Fine Gael)
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This afternoon's IMO presentation states that NCHDs may instead pursue shorter training overseas under superior conditions with the aim of taking up a consultant post with an overall package of terms and conditions of employment, working conditions and salary levels that are more attractive than in Ireland. This is best exemplified by the IMO boarding pass campaign which saw over 800 NCHDs indicate their intention to leave the Irish health service by signing a symbolic boarding pass to make the point clearly that unless things change there will be more NCHDs in our airports than in our hospitals. That is a fairly strong statement to make to the Oireachtas Joint Committee on Health and Children. Part of the frustration - we saw the "Prime Time" programme a couple of weeks ago, we read the newspaper and we listened here this afternoon - is we are caught between the shore and the sea. Are there changes happening? This afternoon the committee was told patient care is being jeopardised. If that is the case, all of us are culpable because that should not happen in the health service. I would hope that is not happening.
Ms Laverne McGuinness:
I will ask Mr. O'Brien to deal with the matter of contracts.
Deputies Regina Doherty and Catherine Byrne raised patient care. Patient care, risk to patient and the management of risk is the business of everybody in the hospital and across our entire services, be it the NCHD, the nurse, care assistant or consultant. It is managed in that way. We have clinical directors in all of our hospitals and at all times, not only on this issue, there is an assessment of risk and risk mitigation factors put in place.
We have acknowledged we are not happy that we have not achieved the 48-hour compliance. They set out here the significant challenges in dealing with it. We are saying we have some work done on the rosters that are now there, the reduced on-tier call and the cost cover ranges. We have those changes made. We are making more changes in terms of ensuring that the NCHDs are not doing work that could be done by other staff in the hospital. That, likewise, will free up more hours for the NCHDs so that they need not work extra hours. Similarly, we are looking at the range of services being provided in our smaller hospitals. That framework is just ready. It will be published over the next number of months, as will be the configuration of hospitals. All of those are on the platform of reducing risk to ensure the safety of services that are being provided.
There is much more work to be done. One of two major measures that we would see as risk reduction - one can never totally eliminate risk - is to ensure that by the end of March there is no doctor working over 68 hours where there are outliers because we have smaller hospitals in quite remote locations that would not have the number of junior doctors in place to support larger rotas than what are currently in place. The other is, coterminous with that, by June that there would not be anybody working for a full 24 hours. There is a full range of measures set out. That is done in co-ordination and in consultation with our clinical directorate.
Those are the steps. Some progress has been made. There has been quite significant progress in some areas. There is a road more to travel. We have committed to travelling that road to ensure that the maximum amount of care can be provided across the hospitals and that we can deliver on the full volume of services that we set out in our service plan, while at the same time balancing the issue of patient safety, which cannot be compromised, and the hours worked by the current cohort of junior doctors that we have in play. Obviously, that is augmented by the training programme that is in place with our medical, education and training bodies and by the extra NCHDs who are being put in place. Given the significant challenges of where we are, both financially and in our HR reduction count, we have been putting measures in place in order to protect the patients and we recognise the duty of care to our junior doctors, but there are outliers whom I acknowledged. There are junior doctors who are working far in excess of 48 hours.
Deputy Regina Doherty mentioned one doctor who got overtime to the tune of €167,000 in the south east. We have looked at that. In fact, it is not something that should have happened. What happened in that particular instance is that almost 50% of that was worked by the junior doctor when on leave and it was worked in a different hospital, which is why there was the extortionate amount of overtime. That hospital, which is in the south east, has reduced its agency and rosters by approximately €2 million. It is taking the cost out of the system and it is being addressed. It is an outlier. It should not have happened.
Regina Doherty (Meath East, Fine Gael)
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Can I ask-----
Jerry Buttimer (Cork South Central, Fine Gael)
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Sorry, Deputy Doherty, I call Deputy Ó Caoláin and Senator Burke first.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I repeat my query to Ms McGuinness about July. I heard what Professor McGovern stated. Is there sufficient confidence that there will be a full complement of NCHDs? It would be a temporary solution at any time, but here we are, year on year, looking to it to fill the gap. We will deal with the bigger issue on another day. Today we merely want certainty that there will be sufficient in situ come July.
On the second of the two points, Ms McGuinness made reference to the 24 hour on-site shift. On the top of page 5, her opening statement states that a key issue is the extent - we were echoing what the NCHDs had stated - to which part of the current NCHD workload is more appropriately delivered by other staff.
It then states that the HSE will be requiring hospitals to identify specific non-medical staff. Why is that still being planned rather than already taking place? Surely nursing staff should have already been asked to perform phlebotomy, canalisation, catheterisation and other services. It is something for which the INMO and the NCHDs have argued and I believe they could also take on further responsibilities. What timeframe is envisaged for this consultation, when will it conclude and when will we see action in this regard?
In regard to the indication that the European Court of Justice may rule against Ireland on our failure to adhere to the European working time directive, is this part of the stick that is driving some of what we are seeing in the HSE's statement? How realistic is the fear that such a case may be taken?
4:15 pm
Colm Burke (Fine Gael)
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On the central applications issue, I fully accept that the smaller hospitals make the decisions but the CVs are sent to them before they can make a choice about where to recruit. They are confined in what they can do in this area. I outlined the example of Cavan, which has three vacancies for registrars. The smaller hospitals are not necessarily being given a choice in the CVs that are sent to them and standards have slipped as a result. Where consultants are on one and two, there is significant pressure on everyone. The system is not working for the smaller hospitals.
I accept what the witnesses have to say in regard to legislation on the supervised division but I ask for clarity on the Medical Council's attitude towards individuals who want to transfer from the supervised division into the general division. Will it be able to accommodate such individuals? Previously when people applied to go into the general division they had to undergo a slow procedure with the Medical Council. Have any arrangements been made with the council on that issue?
Sandra McLellan (Cork East, Sinn Fein)
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With regard to the inappropriate tasks to be performed by nursing staff, will nurses have the capacity to cope with their additional duties and are they aware they will be taking on these duties? On the issues of 24 hours continually on-site and the 68 hours in a week, if hospitals fail to comply who will be held accountable and will sanctions be applied?
Regina Doherty (Meath East, Fine Gael)
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The proposals on the table for the next several months are great but a significant gap remains between the reality for those who deliver the services and the stuff that is on paper. How much unrostered, unpaid overtime is being worked by NCHDs at present? Who is responsible for monitoring what are clearly buckets of hours? We have all heard anecdotal evidence about particular blackspots in terms of difficult employment conditions in certain areas of the country. Who is responsible for maintaining the relationship with the human resources people at certain hospitals? The stories we have been told suggest they have been manipulating circumstances to get more hours out of NCHDs by withholding study leave hours or days off. Who is responsible for managing that? There is a definite gap between the evidence given by those who deliver services and the people who are responsible for managing them. There must be a reason.
Mr. Barry O'Brien:
The Chair asked whether we provide a good career structure in this country. As I noted earlier, we never had more consultants in posts and from a salary perspective we are certainly top of the scale in Europe in attractive remuneration packages. We also offer the capacity for both public and private patients to be cared for in our public health system. All of this is within the contractual arrangements for consultants, which has to be attractive from the point of view of career development.
On the question of who is responsible for rosters, we have invested heavily in medical manpower managers over the past ten years and there is one such manager in every major hospital. Together with the consultants, they are responsible for developing NCHD rosters. Obviously, the consultant will sign off on the hours worked, be they rostered or unrostered, and on that basis we have sent out a circular to each hospital directing that hours worked must be paid for once they are appropriately approved by the relevant consultant.
Jerry Buttimer (Cork South Central, Fine Gael)
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Is that not overly reliant on the consultant in signing off? It was noted earlier that the HSE has a role to play as employer.
Mr. Barry O'Brien:
When I speak about the consultant I am referring to the medical manpower manager, the consultant and, I would even say, the hospital CEO. They are a major resource in the hospital and it is appropriate that they be managed and paid correctly and that the hours they work are approved in that way.
On the question of removing some of the tasks more appropriate to other grades, I draw the committee's attention to the public service agreement under which we are operating and, in particular, the commitments to skill mixes and having the right people with the right skills to the job. If the public sector unions approve Croke Park II we will have a significant increase in working hours by the various categories, including NCHDs, consultants, nurses and support staff. We will have capacity, therefore.
I do not think there is a debate over whether nurses are aware of this. We have invested heavily in medical and nursing education and we have significant numbers of advanced nurse practitioners who are ideally suited to be placed in emergency departments to work beside medical teams and act as decision makers at the same time. The committee will be interested to note that our emergency departments are the departments that are most compliant with the working time directive. We are almost completely compliant countrywide in emergency departments with all aspects of the directive. From that perspective, we are investing in enhancing people's skill sets and we are committed to making tasks more appropriate. However, one proposition continues to cost more money and more people, whereas the other proposition changes how people work by reforming what they do. System wide reforms are needed if we are to implement the directive. It is not simply a matter of telling the NCHD or the nurse to do something different. NCHDs are integral to these reforms, as is everybody else, but they will have to be led by senior management, clinicians and clinical directors.
I will ask Professor McGovern to address the question of retention because she is in a better position to comment.
Professor Eilis McGovern:
The issue of graduate retention has deservedly received considerable attention. Momentum began to gain in November 2011, when a workshop was held to specifically consider the issue. The workshop was attended by all the major stakeholders, including a number of trainees and out of it grew an implementation plan and a steering group. The trainees are very clear about their needs and these obviously include working conditions.
However, they are also anxious, for example, about having clarity about the training journey and Senator Burke mentioned that earlier. There is definitely progress there. There is more clarity about the marking systems for entry into training programmes. They are keen to know the duration of training programmes. They think they are too long and, again, the training bodies are starting to respond. The College of Anaesthetists of Ireland introduced a new training programme in July of last year, which is a year shorter and which is what we call seamless, where there is a single entry point and there is not a requirement to do a second interview to get into the second part of the training programme. The Royal College of Surgeons is introducing a similar programme this July, which again will be a year shorter with a single entry point without the need for a second interview several years down the line. These programmes are not pyramidal. They are almost vertical and we want to get away from a system where there is lack of clarity for doctors who start in a certain specialty about whether they will be able to complete that specialty.
They want to know about job prospects at trainee level and at the end of training when they want to enter the workforce. The blueprint for that is the Fottrell report, which is government policy. We will reach the peak number of graduates in 2014, which will be approximately 725. The report was based on projections, a consultant-delivered service and an enhanced primary care and community-delivered service. We need to ensure we provide within the training system the capacity to train 725 graduates and that is what we are trying to do. Over the next few years to accommodate the increased number of doctors, we will need to convert some of the current service grade posts back into training posts in order that every doctor who graduates has clarity about the fact that he or she will be able to access training.
Communication is one of the things they highlighted. They felt isolation and a great deal of work is going on to improve the communications between the trainees, the employer, the training bodies and the different stakeholders in their every day lives. One of the things they highlighted was the need for trust and respect, which is an important message for all of us to take on board, and which is something that should be regarded as a basic right of any employee in any system, and we are listening to them.
4:25 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Ó Caoláin mentioned the EU case against Ireland.
Ms Laverne McGuinness:
The Deputy mentioned that particular case. That was not the forerunner in regard to this. We have identified in our service plan and in each of the regional service plans a requirement for compliance with the European working time directive and each of the regions has a financial target set against that, which they have to achieve through the elimination of overtime. That is what has been set in this regard. We have indicated to the Commission that we are striving to be fully directive compliant by 2014.
Colm Burke (Fine Gael)
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I asked two questions. The first was about CVs being sent to the smaller hospitals without them having a say in what CVs are sent to them. While CVs are sent to them, they are selected by a centralised office.
The second question is whether there have been discussions with the Medical Council about the doctors in the supervised division. Have there been discussions with the council about those who want to stay here and the problem with the HSE in filling the vacancies they are suitable for?
Sandra McLellan (Cork East, Sinn Fein)
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With regard to accountability, will sanctions be imposed on hospitals if they fail to comply with Brussels?
Mr. Barry O'Brien:
On the issue of the CVs, we can only send CVs for those who apply directly to work in that location. These are for service posts, not training posts. That is 15% of the total number of posts we fill on a service basis. Of those, we send the CVs of people who say they would like to work in A, B or C and they are given to those areas for interview.
Colm Burke (Fine Gael)
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The hospitals argue that, previously, they were able to contact people whom they knew were looking for posts. Now they are prevented from doing that.
Ms Laverne McGuinness:
I refer to the key question of who is responsible and accountable. Ultimately, the responsibility rests with the group CEO, the hospital CEO or the regional director of operations. Even though the clinical director plays an important role in that, the ultimate accountability rests with them. They are very much aware of what is required now in this regard.
There is not a monetary sanction. We will deal with this through the arrangements and the individual meetings with them but we hope not to be in that position. However, we will have to take that in the context of the soon to be published smaller hospitals framework and the reconfiguration of hospitals.
Deputy Regina Doherty asked about the amount we pay in overtime, particularly for unrostered overtime. The total time we paid to NCHDs in 2012 for overtime, which is not broken down between rostered and unrostered, was €165 million. We are putting in place a national system and we are going to procurement for it. Some hospitals have individual systems that cater for the categorisation between rostered and unrostered. We do not have those figures broken down nationally.
Professor Eilis McGovern:
Senator Burke asked about the supervised division. The HSE has been working closely with the Medical Council since last October on a project to assist the 221 supervised division doctors who have expressed a wish to stay in Ireland after their two years are up and the HSE has funded four additional staff to work in the council to assist with the increased workload.
Regina Doherty (Meath East, Fine Gael)
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I am still concerned, notwithstanding the plans afoot. If I am a doctor working in Ballymuckridge and I am being taken advantage of off balance sheet by the person I am working for, where do I go? Who is there to listen to me? Who is there to help me to resolve that issue today?
Mr. Barry O'Brien:
In the first instance, we have regard for everybody's rights and entitlements. One is quite entitled to bring that to the attention of the appropriate senior manager in the hospital. We are not in the business of taking advantage of somebody off the books or in some other way. Getting to working time directive compliance is a challenge but to suggest that we would not show due regard for our employees would not be accepted. Clearly, there is a requirement on everybody and if there are issues or instances that doctors want to bring to the attention of management, they will be dealt with.
Jerry Buttimer (Cork South Central, Fine Gael)
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Is the HSE happy that there are sufficient personnel to recruit in July and that what happened two years ago will be avoided?
Jerry Buttimer (Cork South Central, Fine Gael)
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One of the complaints we hear from both family members and NCHDs is that they have to go abroad and we are asked why they cannot stay at home and why has a pathway not been put in place for them. I have three e-mails from parents of NCHDs complaining that their son or daughter has to go away, notwithstanding the fact that some of the them want to travel. However, in some cases they do not and they feel they have to go.
Professor Eilis McGovern:
Currently, the structure of training is pyramidal and, therefore, we have enough training places for every graduate to get onto a basic specialty training programme but the step from basic to higher specialist is numerically a big challenge. However, to cope with the Fottrell report numbers and to give graduates certainty, we will work hard to convert non-training posts back to training posts. It will not be vertical but allowing for the normal attrition that happens at different stages going through a training process, the goal will be that every graduate has access to a training programme, which will, ultimately, result in a certificate of specialist training.
4:35 pm
Jerry Buttimer (Cork South Central, Fine Gael)
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It struck me during the doctors' presentation that their conditions have deteriorated. We have been told that. Surely that should not be the case.
Ms Laverne McGuinness:
The conditions should have improved in relation to the number of training posts we have in place and the structured programme that is in place. The conditions should have improved with regard to that. Perhaps we might have a separate discussion with the representation on that.
Regina Doherty (Meath East, Fine Gael)
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I appreciate what Ms McGuinness has said. If my problem is being caused by the senior manager in question, can I get the name of somebody else? Where else can I go in that situation?
Regina Doherty (Meath East, Fine Gael)
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What happens when study leave is withheld, or things like that? Where can those disputes be resolved if they are-----
Regina Doherty (Meath East, Fine Gael)
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Thank you.
Jerry Buttimer (Cork South Central, Fine Gael)
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Ba mhaith liom buíochas a ghabháil le baill Feidhmeannacht na Seirbhíse Sláinte. I thank the delegates most sincerely for attending this afternoon's meeting. I appreciate their giving of their time, their presentation and their engagement with members. I thank the members as well.