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.