Jerry Buttimer (Cork South Central, Fine Gael)
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The subject of the meeting is the recruitment, pay and conditions of non-consultant hospital doctors. This is set against the debate we have had as a committee, culminating with the publication of a joint committee report in July 2012. This year we met on 5 March to discuss the concerns of the committee regarding the non-consultant hospital doctor issue. We have also met representatives of the Irish Medical Organisation and the non-consultant hospital doctor committee to hear concerns. We have met Mr. O'Brien on a quarterly basis, as well as other representatives of the HSE and the Department of Health, and we have discussed recruitment, pay and conditions of non-consultant hospital doctors. Many members of the committee have expressed serious concerns about the issue and we hope today's meeting will bring clarity in that regard.

I welcome the guests and thank them for coming before us today. Before commencing I remind witnesses and members of privilege. Witnesses are protected by absolute privilege in respect of their evidence to the committee. If you are directed by the committee to cease giving evidence in respect of a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against a person or persons or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official in such as way as to make him or her identifiable.

I welcome Ms Clodagh Murray to the Gallery, as she is on a work experience programme in the Houses. Mr. O'Brien can now make his opening remarks.

Mr. Barry O'Brien:

I thank the Chairman and the committee for the invitation to attend the meeting today. I am joined by a number of my colleagues, Dr Ciaran Browne, national lead, acute services, Professor Eilis McGovern, director of medical education and training, and Mr. Andrew Condon, general manager, human resources.

Non-consultant hospital doctors, NCHDs, play a very important and fundamental role in the provision of services in our hospitals. 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 increase intern posts from 570 to 639.

The HSE recruits a small proportion of NCHDs. There are two types of NCHD posts: training posts and service posts. Some 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 recent years. Addressing this issue has been a priority for the health service and has included a number of recruitment programmes internationally. This has meant that over the past three years, the majority of NCHD posts – 98% - are filled normally. Where staffing issues exist, there remain sufficient agency staff to meet service needs. This means that the hospital system has operated with a small ongoing vacancy level in recent years. In this context, a challenge facing the health service is that higher payments to agency staff have incentivised NCHDs to leave normal employment and work for agencies with the expectation that they will be hired back by hospitals. This is particularly relevant in emergency medicine and psychiatry.

NCHDs are recruited twice a year – in January and July – to accommodate training rotations. A number of recruitment processes are under way in preparation for July 2013. Postgraduate training bodies are filling posts on training schemes. The HSE centralised applications process directs applications to hospitals. Local recruitment is being done by HSE hospitals and agencies, where candidates are selected and interviewed and a decision is made to fill posts. There is external recruitment in South Africa, focusing on emergency medicine. There is an agreed process with the College of Physicians and Surgeons Pakistan to rotate their trainees into Irish hospitals as part of their training scheme in Pakistan before they return to training posts in Pakistan.

Particular concerns identified regarding recruitment for July 2013 include changes in the quality of applicants to some sites in terms of training or experience, the ongoing requirement for registrar level doctors in emergency medicine and anaesthesia, who are in short supply internationally, and the consequences of ongoing adjustment of training schemes to ensure participants have a reasonable chance of competing successfully for consultant posts. This means that some schemes are reducing the number of training posts, albeit the proportion of training posts continues to increase.

Specific actions are being taken to ensure posts are filled. The HSE medical education and training, MET, unit and the integrated services directorate, ISD, have worked together with the College of Physicians and Surgeons Pakistan to place trainees in a structured training programme in Ireland for two years. The interview process, which was conducted in conjunction with the relevant postgraduate medical training bodies, indicated that applicants were of a high standard. This initiative is likely to yield up to 30 doctors in 2013 but has potential for greater numbers and additional specialties in 2014 and beyond. This will be of significant benefit to emergency medicine, a specialty that has been consistently at risk of vacancies over recent years.

Earlier this year, the HSE engaged two recruitment companies to begin the process of sourcing additional doctors from South Africa. This was initially focused on access through the supervised division, but revised access rules for general registration based on South African intern equivalency from 2006 required a change in approach. Initial reports from the recruitment companies indicate potential availability of ten to 20 candidates, primarily in emergency medicine, with limited numbers across other specialties. Depending on specialty match, the HSE will assign these doctors to work in hospitals with traditional recruitment challenges, such as in Drogheda and Letterkenny. Since February, the HSE has provided four administrative staff to the Medical Council to support the efficient and timely registration of doctors prior to the July rotation.

In ongoing local and national recruitment, the normal NCHD recruitment process is taking place in parallel with the measures just mentioned following advertising by the national recruitment service nationally and internationally. Delays in confirming fill rates for training scheme posts and timeframes for interviews create difficulty in accurately reporting on vacancies. Current data indicate that approximately 200 posts remain to be filled for the July rotation. These constitute 4% of all NCHD posts. Vacancies are concentrated in three specialties at registrar level - anaesthesia, general medicine and emergency medicine.

Alongside the measures just described, hospitals experiencing particular challenges have been authorised to advertise nationally and internationally in addition to broader HSE advertising. Hospitals are also evaluating revised NCHD rotas and, in exceptional circumstances, the use of agency staff. This latter option is clearly a last resort given the financial implications. Vacancies are generally located in small to medium size hospitals which have limited consultant numbers and do not have the volume or complexity of activity to support training posts. Taking account of trends in filling posts over recent weeks and noting that the system operates with an ongoing vacancy level, it is anticipated that the vacancies will reduce day by day in the period up to 8 July.

The HSE is a partner in an NCHD graduate retention initiative established in 2012. As part of this initiative, appropriate support services for trainee doctors are being identified and trainee doctor representatives, who will represent the concerns of trainee doctors at a senior level with the hospital management structure, are being appointed. Key concerns in terms of retention are long working hours and pay for hours worked. In this context, the HSE has established a national implementation group to progress compliance with the requirements of the European working time directive, EWTD, and to facilitate introduction of electronic time recording and rostering systems. The Minister for Health has indicated to the European Commission that he is committed to full implementation of the EWTD for NCHDs by the end of 2014.

Each hospital and agency has prepared 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 with a particular focus on two key targets. These are a maximum working week of 68 hours and a maximum period on-site on-call of 24 hours. The national group has just completed a process of site visits to each acute hospital and will report in coming weeks on the extent to which NCHDs are compliant with the 68 hour target.

Under the public service sustainability agreement, which the Irish Medical Organisation, IMO, is recommending its members accept, the IMO and the HSE have agreed, under the heading "retention of graduates of Irish medical schools" to:

review the current public health and community medicine, NCHD and consultant career structure with the aim of further developing the career and training pathways from intern to consultant-specialist level. This will take account of service needs, training and service posts, the health reform programme, the urgent requirement to reduce NCHD working hours and developments in relation to EU legislation. The overall objective is the retention of graduates of Irish medical schools within the public health system and the attraction back to Ireland of such graduates - where they have left previously. The management side and the IMO will begin the process by June 2013.

There is agreement on the principle underpinning the savings that may be realised from task reallocation but there is also debate on the quantum of savings that can be achieved. Taking that into account, the parties have agreed that an intensive evaluation process should take place on a number of acute sites, at Beaumont, Tallaght and the Mater, to identify realisable cash savings. The process is under way.

I shall conclude my opening statement. I, together with my colleagues, will be happy to answer any questions.

Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome the guests and thank them for attending. I thank Mr. O'Brien for his presentation and for highlighting the current situation. It is reassuring that a commitment has been given to provide a career path and retain graduates. At the same time vacancies exist in key areas as Mr. O'Brien's outlined in his report Anaesthesia, General Medicine and Emergency Medicine at Registrar Level. I call on Deputy Ó Caoláin to commence because, in the absence of Fianna Fáil, he can take the lead.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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My party would do so at any time.

I presumed that the opening statement by Mr. O'Brien was going to be followed by others of his colleagues.

I join with the Chairman in welcoming the delegation. We are readdressing the issue even though it is a short period since the quarterly meeting. It underscores the high level of concern by the level of the Oireachtas joint committee regarding the reality of NCHD cover at a number of hospital sites around the country as of July.

On the last occasion Mr. O'Brien attended he indicated the recruitment target from Pakistan as being 20 NCHDs for each of the specialties of anaesthesia, emergency medicine and surgical specialties was identified but that the target would not be "achievable in anaesthesia, in particular." Those were his words. Is that still the case? What is the up-to-date information on anaesthesia, in particular, and the targeting of Pakistan?

With regard to South Africa, we were told of a potential availability of ten to 20 candidates out of a set target of 60. Again, there has been a major shortfall. What is the current position?

We have the incredible situation, that was also mentioned in the five page report, whereby higher payments paid to agency staff are incentivising NCHDs to leave their normal employment in order to take up agency posts. This is done on the basis that they will then be re-employed in the vacancy created through agency appointment or deployment. Clearly, those posts are not open to being filled in the normal way under the current employment embargo. Can Mr. O'Brien comment on the matter? Is it true that when an NCHD person leaves a post to join an agency, the post can only be filled by agency staff? Does that not highlight the need for more NCHD posts, initially? I emphasised the word "initially" because I believe that the committee is of one mind in wanting to implement its recommendation to create new grades and a new career path, in the first instance, for young Irish trained doctors working in the health system. What is the position as of July? What is the shortfall? How will it impact on patient care?

The Chairman does not have a bell but he has a big mallet that he may hit me with when I mention the following. At the end of last week I received a parliamentary reply to a question that I tabled on Letterkenny General Hospital. It is one of the specific hospital sites that I have instanced as a particular area of concern. I shall conclude by pointing out that a reply received from Mr. John Hayes, Donegal area manager, HSE West confirmed the serious situation that pertains at the hospital. I have highlighted the matter here before. The situation at Our Lady of Lourdes Hospital, Drogheda, is particularly acute. Mr. Hayes indicated that every effort was being made but stated:

However, key challenges still remain in some specialties and particularly in respect of Registrar grade doctors. This is especially true in the Department of Medicine where the requirement for locum registrars is expected to be close to 50% of the total in that department.

Dialogue with the Royal Colleges & the HSE Medical Education & Training Unit has enabled Letterkenny to designate a greater proportion of existing NCHD posts as formal training posts. The hospital has also engaged medical agencies to source doctors for key posts.

Colm Burke (Fine Gael)
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I thank the panel for attending. I appreciate their work and acknowledge that they work in a difficult area. It is not easy to manage 4,700 junior doctors and its a different issue again to manage them in individual hospitals. I hope that anything I say is not taken as a personal criticism.

I shall follow the comments made by Deputy Ó Caoláin on emergency medicine. There is a major crisis in emergency medicine due to the expected shortfall of around 28%. The current figures state that Tallaght will be short two out of five, Limerick three out of six, Cork four out of seven, Drogheda five out of nine, Loughlinstown two out of three, Galway two out of eight and Castlebar two out three. There is also a major problem in the northwest region with a shortfall of around 80 in medicine. There are also particular problems in Letterkenny and Portlaoise due to a shortage of two out of three registrars in the obstetrics and gynaecology unit.

My other concern relates to the 2003 report. It contained a commitment that we would have 3,600 consultants by 2012 but we have only 2,500 consultants at present. Recently I got the figures on the employment of a registrar for six months which had a provision that positions could not be filled on 1 July. There is now a commitment to give two agency posts to registrars. The cost of the registrar for six months is €125,000. Should we return to the Hanly report of 2003 when reviewing the junior doctor process? Is it not cheaper to employ five consultants rather than have three consultants and four registrars? Should we reduce the number of registrars? We have not revisited the sector. The use of agency staff will incur great costs for the HSE and lead to an overrun in its budget. I agree with Mr. O'Brien's report that where the junior doctors are aware of shortage, they are leaving posts in order to fill them again under an agency contract.

The first issue is about reviewing this entire issue - in the smaller hospitals in particular - as to whether we should review the employment of consultants, as opposed to junior doctors. The second issue pertains to scenarios in which junior doctors have agreed to take posts but then have received a better offer from somewhere else. I understand this has happened in a number of hospitals in the past two months, whereby such doctors, having agreed to take up a post, have walked out of that post to take up another, thereby leaving the smaller hospitals high and dry. I raised the third issue, concerning the people who had come in from Pakistan and India, at a meeting last February, when I also wrote to the HSE in this regard. I was concerned that no procedure had been put in place to get them onto the general division of the register. I now understand that of the 300 who came in, only approximately 74 will remain in Ireland after finishing their two years. Do we need to learn what went wrong that of 300 people, only such a small number have decided to remain in Ireland?

I have a further issue in respect of training bodies. While 81% of junior doctors are in what are recognised training posts, there appears to be no co-ordination about such training posts, in that a huge number of doctors still must reapply after six or 12 months to continue in their rotation. Is there a need to meet the training bodies to tell them the current system is not working? Is it the case that there is a need to talk about a fresh approach to this issue? This system has been in place for the past 25 years and problems with it are being encountered. Moreover, on the administration side it also is placing huge pressure on the HSE and were it not necessary to spend so much time on such matters, the HSE could be doing many other things. Is a plan in place for the next two to five years in respect of dealing with this issue? While 2011 was a difficult year, 2012 was more difficult and at present, in 2013, no real improvement has been made in respect of the problem that arose in 2011.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I thank Mr. O'Brien for the presentation. I ask the witnesses to focus on many of the points raised by Senator Colm Burke. First, I am the mother of a non-consultant hospital doctor, NCHD. He entered that career full of hope, having wanted to be a doctor since he was eight years old. However, both he and his colleagues are really frustrated and their morale is really low. While Mr. O'Brien talked about a career path, I do not know what career path because all I know is that he does interviews every six months and every 12 months. He and many of his friends have been obliged to emigrate and it is very frustrating for them. I did not speak to him before today's meeting because sometimes it is very difficult to listen to him or even to get him, because he appears to be working all the time. I note the junior doctors put forward the idea that starting in their first year, they should work for two years as junior doctors, rather than the single year they work at present before being obliged to go abroad or to be placed again. In many of the hospitals mentioned that are having difficulties, there is no proper career path for these kids.

In addition, I note another relative sat the leaving certificate examinations last year, secured 600 points but did not get into medicine. It galls me when I hear the HSE is trying to bring people into the country because we do not have a sufficient number of doctors and yet kids whose leaving certificate results yielded 600 points did not get into medicine. This is disgraceful and I refer to kids who are sitting the leaving certificate exams today. While I believe the position in respect of the HPAT exams will be changed next year because it has failed, there are kids who came through our system but did not get into medicine although they really wanted to so do and who have gone abroad. Some of my son's friends have trained in Wales and England and are doing very well. They now are fantastic doctors in the English system. We are supplying New Zealand and Australia with the best doctors but cannot employ our own doctors. Consequently, we really must consider their career path. I ask the witnesses to comment specifically on the proposal for two-year rotas for junior doctors in Ireland, rather than the current one-year rota. While I have said all I have to say, I must tell Mr. O'Brien I get really annoyed when I hear him talking about trying to bring doctors into the country. Why do we not train enough doctors and give them a proper career path in this country?

Mr. Barry O'Brien:

I would like to make some general comments regarding each question raised and Professor McGovern, Mr. Condon and Dr. Browne will then deal with all of the questions specifically, because some facts were raised by Senator Colm Burke, as well as by Deputies Mitchell O'Connor and Ó Caoláin, on specific locations. On the issue of agency recruitment, I reassure the joint committee that the HSE has no interest in employing people on an agency basis. We do so only when there is a crisis. There is no current embargo and nor does the moratorium impinge on our capacity to employ NCHDs in an NCHD rotation. However, given the nature of our hospital system and structure, as well as the manner in which training places are approved and authorised by the training bodies, there will always be a percentage of posts which will be what are termed service posts only. In other words, to sustain our hospital infrastructure, there will be service posts and there are, for reasons best known to the doctors themselves, people who are not interested in a career path or in any sort of career ladder. They simply are people who are interested in maximising their earning potential by working on an agency basis and as a freelancer wherever they get the work.

Jerry Buttimer (Cork South Central, Fine Gael)
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As matter of interest, what percentage are service posts?

Mr. Barry O'Brien:

The service posts are 19% and to be fair, that is one of the issues. Another issue is we have never had more consultants employed in the public health system and have never had more NCHDs employed in the public health system. It is important to point out that while the Hanly report recommended a redistribution involving more consultants and fewer NCHDs, the HSE has been ploughing ahead in increasing the numbers of both. There certainly are challenges and there certainly is a need to revisit this issue. The HSE is committed, with the professional organisations representing all NCHDs and consultants, to engage in that and we will start that process next week. However, there certainly are lessons to be learned in this regard and things to improve. I will ask Professor McGovern to deal specifically with Deputy Ó Caoláin's issue in respect of Pakistan and others. Mr. Condon will deal with the issues raised on a hospital basis by Senator Burke. He also will comment on the issue raised by Deputy Mitchell O'Connor.

Professor Eilis McGovern:

To answer the question about the initiative with the College of Physicians and Surgeons Pakistan, it is important to note this was a pilot project. This is the first year in which we have done this and there is a learning aspect to it. While we targeted initially 60 doctors in three specialties, as we stated previously, we were not going to compromise on the standards and the safety of these doctors. We set the standards high and we made this point to our own training bodies from the point of view of selection. The Medical Council also has a role in respect of patient safety. The difficulty in recruiting sufficient doctors for anaesthesia was related to their experience, in that the issue pertained to the minimum experience we required for doctors to work in the Irish health system. On the contrary, we got excellent applicants for the surgery programme and all 20 posts were filled, although one subsequently was withdrawn because the person did not have the Medical Council requirements. Next year, we will have learned from this experience and if we decide to have a programme such as this for 2014, we will apply what we have learned, at both the Pakistan end and the HSE and Medical Council end, to ensure we get the right doctors. The important thing was not to compromise on the safety profile of the doctors who were coming to work here.

Mr. Andrew Condon:

I might comment specifically and briefly in response to a comment made. I personally was involved in the recruitment of doctors in Pakistan a number of years ago. They were interviewed in English in Pakistan by our consultants and by human resources staff and they passed an English test with the Medical Council in Ireland before being able to take up work. I think that is an issue that is of concern and we also have a provision we have circulated to all employers that in cases in which an employer has concerns regarding the English language capacities of any health staff member, the employer can ask that staff member to undergo the international English language testing system, IELTs, test.

If they fail the IELTs, it would have consequences for their continued employment. That is an issue we take particularly seriously.

As regards the overall NCHD staffing issue and why Irish doctors do not occupy 100% of the junior doctor posts in this country, it is important to realise that since the 1990s approximately 50% or slightly more than that of the doctors who staff our hospitals have been recruited from outside this country. Over the past ten years there have been concrete efforts to address that. The Fottrell and Hanly reports were drawn up. Senator Burke referred to the latter. The Fottrell report mapped out a route suggesting that we could be self-sufficient in terms of medical graduates. In recent years as part of that process the HSE has increased the number of interns who are the first grade of junior doctor fresh out of medical school. That increase will continue. Professor McGovern can take up the issue in a moment. It will mean that we will have a decreasing reliance on doctors recruited from outside Ireland. In parallel, we have also increased the number of consultant posts by more than 500 in the last five years. Actions are under way to address systemic problems.

As regards the overall NCHD staffing position for July, which Deputy Ó Caoláin and Senator Burke in particular mentioned - reference was made to Letterkenny - this is indicative of a process that takes place every year through which we are addressing aspects of the process on a developmental basis. For example, a number of weeks ago Letterkenny was reporting 60 vacancies out of its cohort of just over 90 doctors. Today, our information is that Letterkenny has eight vacancies. That is paralleled in other sites around the country. What it illustrates is that on a day-by-day basis from April onwards each year the number of vacancies-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am sorry. Is there is a mobile telephone near a microphone? Could witnesses please switch their mobile telephones off?

Mr. Andrew Condon:

On a day-by-day basis the number of vacancies change. We would anticipate that by July we will have a much lower number than the 200 that have been reported today. General medicine has been highlighted as a particular issue. One of the influencing factors is our efforts to progress compliance with the working time directive to achieve a better working environment for doctors, something which Deputy Mitchell O’Connor referenced.

One of the measures to improve working conditions for doctors is to put larger numbers of doctors on particular rotas where they are appropriate. What we are seeing at the moment is that to some extent one of the reasons doctors are moving around the country is to take up posts in some of the larger sites, as opposed to the smaller sites. One of the solutions to that is to increase the number of consultant posts and lower rotas. In obstetrics, for example, we have a number of hospitals where there are three obstetricians providing cover. Senator Burke mentioned that one of the solutions to this was to increase the number of consultants. We have offered hospitals experiencing those kinds of problems the facility to apply for additional consultant posts in place of existing NCHD posts, for example, in Letterkenny. The offer has been in place for some years. In terms of growing consultant numbers-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Has the offer been taken up by Letterkenny?

Mr. Andrew Condon:

It has been taken up a number of years ago for certain specialties. One of the issues in Letterkenny and similar hospitals is the structuring of the medical workforce. Another issue mentioned was the number of training posts in Letterkenny. There is a parallel between having additional consultant numbers making sure junior doctors are in training and that people in whom one invests locally in terms of training and education come back to work in the hospital. As part of that, one of the issues we are confronting in Letterkenny is increasing the number of training posts there.

Professor Eilis McGovern:

Certainly, this year, for the first time Letterkenny has been recognised for higher training in anaesthesia and two specialist registrars are going there in July. Also, six of the trainees coming from Pakistan are going to Letterkenny, two to emergency medicine and four to surgery. There is also a senior registrar in surgery going to Letterkenny this year. We are working with the training bodies to try to address the issue mentioned by Deputy Caoimhghín Ó Caoláin, namely, the distribution of trainees within central hospitals and more peripheral hospitals. We all recognise that there is an excellent training opportunity for young doctors in peripheral hospitals. We are trying to get that balance better distributed and we are working with the training bodies on that.

Jerry Buttimer (Cork South Central, Fine Gael)
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Senator Burke referred to figures. I did not note all of them. Will the witnesses address the point? In his presentation, Mr. Barry O’Brien, and Professor McGovern, referred to difficulties at registrar level in anaesthesia, general medicine and emergency medicine. Senator Burke outlined figures, one of which related to Cork. Was it the emergency department?

Colm Burke (Fine Gael)
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The figures suggest that four out of seven posts are vacant in Cork and in Castlebar it is two posts out of three vacant.

Mr. Andrew Condon:

Two issues arise with figures. The figure I had for Letterkenny last week is not the figure we have today, which is substantially lower. That is replicated across the country. Figures are a snapshot in time.

Colm Burke (Fine Gael)
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Last year-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Could we have one speaker at a time? When Mr. Condon has replied I will allow Senator Burke to respond.

Mr. Andrew Condon:

For example, last year and in previous years substantial deficits in emergency medicine were reported. One of the key issues for us as a service is that we have an ongoing vacancy rate in certain specialties and yet there has been no diminution in the service provided year-on-year. We have provided an initial level of service as a health system year-on-year despite the ongoing vacancy rate.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Ó Caoláin referenced Letterkenny and the reply he received to a parliamentary question in which he was told that there would be a withdrawal of service. Are we happy that there will be no withdrawal of service?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The response is dated 6 June and this is 11 June.

Mr. Andrew Condon:

Our information is from 11 June, five days later. The Deputy received a communication that there were eight vacancies in Letterkenny. He also referred to 80 vacancies across the north west, which I presume is possibly Mayo but more likely to be Sligo and Letterkenny. Again, our information is that the figure is substantially lower. I put a warning tag on individual figures taken at a certain date given the dynamic nature of the situation. We have been in this place repeatedly in the past three to four years, where in May or June we have a certain vacancy rate but by the time we get to the NCHD rotation date in July what we find is that we have to make no reduction in services and the staff employed often provide a higher level of service. I will ask my colleague, Dr. Browne, to comment on the actual response we would have if there was a service issue.

Dr. Ciaran Browne:

To follow on from what Mr. Condon said, each service has a clinical director and a hospital manager who is projecting forward as to what the potential vacancies will be. Each of those hospitals must make their adjustments based on the projections but we must also acknowledge the fact that there are a lot of modernisation, service improvement and initiatives happening at local level. We have referenced some of them previously such as the reallocation of some of the tasks previously carried out by junior doctors to nurses, but also a lot of the business processes that are used within hospitals are being significantly improved, as well as the clinical programmes that are under way across many hospitals. There is much good work going on that helps to cushion the impact of any reduction or vacancy levels in hospitals.

As Mr. Condon acknowledged, there are hospitals which previously carried a vacancy and therefore the numbers quoted today might not necessarily be an increase in the current vacancy rate and they are covering the gap in the number of vacancies by potential-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I wish to stop Dr. Browne for a moment. In my experience and from talking to colleagues, the clinical directors are making representations to us either on the basis of our committee membership or individually to express concern at what is happening and the impact that could be felt in July. I accept the bona fides of Mr. Condon that today’s figure will be different from next week’s figure but why then are clinical directors coming to committee members to voice criticism of the process? Why, in the case of Deputy Ó Caoláin and Senator Burke, was it suggested to them that there would be a diminution in service?

Dr. Ciaran Browne:

Clinical directors are expressing concern because they are looking forward to what potentially might be their vacancy rate and they are making adjustments based on potential contingency plans they might have to put in place. As Mr. Condon said, we have been in this situation previously and there has been no diminution in services subsequently. In some cases there might be a requirement to reduce some services, for example, outpatient services, but many of those decisions are made on the basis of local priorities. For example, the contingency plan that one might need to put in place for a large tertiary hospital such as Beaumont Hospital will be significantly different to perhaps a smaller hospital in another location.

Each of those clinical directors is making those adjustments. It is a dynamic situation and at the moment they are trying to put in place those contingency plans should the need arise. Previously we have seen other initiatives that helped with the potential impact any vacancy rates may have caused.

Jerry Buttimer (Cork South Central, Fine Gael)
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Surely we should not be in a situation year on year where this question arises?

Dr. Ciaran Browne:

Senator Burke raised the issue of doctors from India and Pakistan staying on. Initially we recruited 220 doctors from those countries and they were placed on the supervised division within the Medical Council. The individual registration of a doctor is between the doctor and the Medical Council, while the HSE is interested in facilitating the transfer of many of those doctors from the supervised division to the general division.

Last year we began a process with the Medical Council to specifically create additional capacity to facilitate the transfer of those doctors from India and Pakistan to the general division. We have supported the Medical Council with additional administrative support so the documentation and all the administrative processes associated with registration could be fast-tracked through the system. The HSE has been working with the Medical Council to ensure the opportunity for those doctors to take up registration is in place and we have worked with each of the individual doctors to see how we could assist them in the transfer.

Of the cohort of 220 doctors, we would not expect all 100% of them to stay on, they make individual choices based on career or family considerations, but we have worked to create the capacity within the Medical Council to facilitate that registration process.

Mr. Barry O'Brien:

We are responding as a health service by having more people in training than ever before. We have increased year-on-year the number of interns, as recommended in the Fottrell report. It is a reflection on the quality of the training in Ireland that many Irish doctors decide to travel the world and practise their profession in other locations, despite the fact we have increased by 500 the number of consultant posts that have been available. That is the nature of the profession; people travel in other professions when they have a globally recognised credential.

The very nature of our rotation twice a year in January and July, based on the requirements of the training, means that other statutory agencies have a contribution to make if there is to be a fundamental change in the dynamic of how we plan and deliver medical education and training and we are working with each of them. Around this time every year, the level of vacancies changes on a daily basis. This time last year, May was a crisis month and by the third week of June, every slot was accounted for. I am not saying the same will happen this year, but that is the nature of the business we are in when it comes to situations like this.

Professor Eilis McGovern:

I reiterate Mr. O'Brien's remarks. Someone asked if this is a recurring problem every July and if there is any long-term plan. The long-term plan relates to reducing the number of service posts. Vacancies occur in the service posts, the training posts are mostly filled by our own graduates. About 20% of posts are service grade posts and that is why we depend on doctors coming from other countries. Our plan is to convert most of those posts to training posts in the next two to three years. We need to create those training posts to build capacity in the system for the Fottrell graduates. We have gone from 340 graduates per annum to 725 expected next year, when the Fottrell numbers plateau. If we could envisage in two or three years' time a situation where we had more intern posts, more trainee posts and many fewer service grade posts, perhaps 200 fewer, the recurring nature of the vacancy problem in July would recede greatly.

I reiterate the remarks I made the last time we were here. We have an international responsibility to train doctors from low and middle-income countries. It would never be our goal to be completely self-sustaining. Every First World country traditionally trains doctors from less well-off countries so they can go back to those countries and add value to their health services.

Jerry Buttimer (Cork South Central, Fine Gael)
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That point is well made and should be highlighted more; it gets lost in translation.

Dr. Ciaran Browne:

In the longer term, we want the hospital trusts not only to create opportunities for better patient care, but to allow us to hire doctors to a hospital group and then structure the rotation of those doctors in a much more systematic way than has been the case to date, where individual hospitals compete in recruitment for services they are providing. In hospital groups, hospitals can recruit through the hospital group and then rotate the doctors, which will help Letterkenny because it will form part of a group, and Drogheda, where recruitment is a larger process.

Mr. Andrew Condon:

On the issue of why doctors must rotate, as raised by Senator Burke and Deputy Ó Caoláin, the report from last year made some useful suggestions. In the intern year, students tend to work in the one location, so during different periods they follow different specialties in that one location. At other training levels, such as senior house officer or registrar, training is split into basic specialist training and higher specialist training and those doctors have a training agreement with their training body. There is, however, a huge degree of flexibility as to where they might fulfil that training agreement and they have a level of individual choice and determination with the training body as to where they can rotate to.

One of the issues is the extent to which the training body can give a doctor a training agreement at the start of the training programme that states where the doctor will be for the next two years, and in terms of higher specialist training, for the next four, five or six years and where the hospital's doctors will rotate to, along with the rotation dates. That will be the ideal scenario with a degree of flexibility built in.

There is a degree of flexibility at the moment and one of the conversations under way with the training bodies addresses how we give greater certainty to doctors and hospitals about who is coming to them and when. The health service is delivered by a variety of different employers. If I am a doctor in training at St. Vincent's Hospital in Dublin and I move to Cork University Hospital, I am moving from a HSE-funded agency to an agency owned and operated by the HSE itself. One of the measures we anticipate will deal with that is the transition to hospital groups that have independent governance. Another issue that will address that is the move to a shared service where instead of multiple payrolls that can lead to problems when changing employment, there will be a single payroll for the health service.

The key issue in doctors' working lives is that they know where they are going and how their career and training are oriented. We are taking that up with the training bodies.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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No one here doubts the witnesses' competence or good intent. This, however, is a space and place where I do not want to have to address this issue again. I hope that at least we are on the one page in that respect.

Mr. Condon talks about a snapshot in time. The numbers he instanced were of 60 out of 90 positions in Letterkenny, and he stated that as of today the number is eight. Is this an ever-decreasing situation and the snapshot tomorrow will not have eight, 18 or some other figure?

Is it at least an underlying certainty that this is the case? Dr. Browne and Mr. Condon and, I believe, Mr. O'Brien and Professor McGovern stated we have been here before. This returns us to the point that we do not want to be here again. We must face the reality that this is a ramshackle system in which a flawed approach is taken to dealing with highly skilled and qualified young and not-so-young doctors. We must do much better, not only for the sake of the doctors in question but for the sake of all of those who depend on their skills. We must get to a better place.

Two years ago, we had to introduce emergency legislation to deal with a crisis. While I acknowledge that the crisis currently presenting is not of the same intensity as the previous one, there is a crisis at a number of a sites. This is reflected to me on a continuous basis. That we have been here previously and the services survived does not give me any comfort. As a Dáil Deputy who covers many issues, health being a large portfolio as a shadow spokesperson, it is a matter of serious concern that it is being flagged to me and colleagues of all political views that we are facing crises where services will not be maintained.

When we seek the opportunity to engage with the Health Service Executive and others, the purpose is to try to find solutions, help and encourage and use our positions to complement efforts being made to arrive at a better place where the likes of this will not take place again. Professor McGovern used the expression, "If we were able to envisage". The joint committee has made recommendations and identified, as our guests acknowledged in their responses, what needs to be done. We must eliminate the dependency on non-consultant hospital doctors who one of our colleagues in this committee refers to in less than glowing terms, making reference to apprentice mechanics. My life depended on a non-consultant hospital doctor during a cardiac event seven years ago and I would have the same trust in presenting if the situation were to take place again. However, we need more consultant physicians and we must reach the position where trainee opportunities are available across the board and doctors have a career path and certainty and are encouraged to remain in the service, especially given the high cost of training from college level onwards.

While we are most certainly able to envisage, we are no longer willing to envisage a repeat of the previous circumstances. I am at the end of my tether on this issue. The answers I have given to those who have made inquiries to me about the five-page report at the quarterly meeting was that it was not worth a ball of blue. I sought further detail, for example, on whether the position regarding anaesthesia and South Africa, respectively, still obtained. With respect to Mr. O'Brien, while I know he is making every effort, I can only take from what he has shared with us that the position remains as it was and we do not have certainty of a full complement across the board, which would erase the concerns of front-line service providers. They are the voices behind my seat and every other seat at this table and they are justifiably unhappy with the current position. We need to be absolutely certain that we are approaching the end of what I just described as a ramshackle approach to the provision of trained doctors in our hospital system. Currently, the system is not fit for purpose and we are going from crisis to crisis every six months. The position is intolerable and cannot be a happy space for those before us who have responsibility for addressing it.

Colm Burke (Fine Gael)
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I am disappointed that no substantial progress has been made in the two years since our meeting in 2011. As I have consistently pointed out, we are able to offer two-year contracts to graduates from Pakistan whereas, and I do not care what the training bodies are saying, we are still stuck with six-month contracts for people who are on training programmes. Given that this problem was evident two years ago, I fail to understand the reason no progress of any description has been made in stabilising the position. Any junior doctor in Ireland can secure a two or three-year contract with two or three different hospitals in the United Kingdom. This has been practice in the UK for the past 25 years but is not being done to a sufficient extent for Irish graduates in our system.

Mr. Condon referred to smaller obstetric units. There are 12 units operating with a one-in-three rota. I know of one unit which sought to recruit a fourth consultant but the HSE withdrew the appointment after interviews had been held. The person to be appointed, who was an Irish graduate, subsequently moved to Canada to work and no explanation was ever given for the failure to appoint a fourth consultant. I do not accept that the smaller obstetric units have been offered four consultants. Many of the hospitals in question are being offered doctors who are at the lower end of the scale in terms of ability. There are people on one-in-three rotas who are working 12 days in a row without a break, not from 9 a.m. to 5 p.m. but until 2 a.m., 3 a.m. or 4 a.m., the reason being that the quality of junior doctors being offered to them has declined significantly. This issue has not been addressed by the HSE in the past two years.

On the recruitment of doctors from India and Pakistan, I have been informed that 300 such doctors were recruited but I will not argue with Dr. Browne who indicated the figure is 220. This year, 30 doctors have been recruited from the region. Did we put our foot in it, as it were, three years ago when we placed doctors who had been recruited from India and Pakistan in rented accommodation and gave them food vouchers for three or four months? I have met senior consultants from Pakistan and India who have received feedback from junior doctors from their home countries that they walked away from positions in Ireland because of the treatment they received two years ago. Is this the reason only 30 doctors from India and Pakistan applied for positions in the Irish health service this year compared to 220 two years ago? These questions must be answered if we are to avoid the mistakes of the past.

The training bodies should not dictate what is to be done if the system is not working and we are not filling posts. While the problem is especially acute in hospitals outside the major cities, I understand that two vacancies in accident and emergency units in Cork city have not been filled since 1 January.

The OECD has been critical of the number of junior doctors Ireland is recruiting from developing countries. What is the deadline for reaching agreement with the training bodies on restructuring our approach to employing doctors? We have the same debate every year and as yet no deadline has been set for establishing a new structure.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I ask why we are not bringing more medical students into the system and why junior doctors cannot be given a two-year rather than a one-year stint in the hospitals. Mr. O'Brien said in his concluding remarks that doctors need certainty but I can assure him that they do not have certainty. As Senator Colm Burke said, they are doing interviews every six months. I cannot think of any other professionals who are doing interviews every six months and who are wondering whether they will be based in Donegal, Cork or elsewhere. I do not know what is wrong with our Irish doctors that they cannot be employed in the system. We are bringing in non-Irish, foreign doctors and I would ask the public if that is what we want into the future. I do not see the situation improving.

Do we want non-Irish junior doctors and non-Irish consultants in this country? If we do, that is fine but if we do not, Mr. O'Brien and his colleagues need to sort out the problem for our doctors. I hear Mr. O'Brien sighing but I know of a number of doctors who agree fully with what I am saying. What is Mr. O'Brien doing to incentivise junior doctors to stay in this country? They are intelligent, bright people who are working in life-and-death situations for long hours. They are ambitious and they work hard. They go to medical school for six or seven years, work in our health system for ten years as non-consultant hospital doctors but then we do not employ them as consultants or we want to pay them peanuts. Nobody has said that here today but we know that is why so many of them are going abroad. We need to talk about this realistically. If we are happy to have non-Irish doctors in our hospitals and non-Irish consultants, that is fine. That is certainly the direction in which we seem to be going.

Professor Eilis McGovern:

I take everything Deputy Mitchell O'Connor has said on board. Some things have changed. In the past, the training bodies and the HSE were quite separate. Since taking up my new role last year, I am a member of the Forum of Irish Medical Postgraduate Training Bodies and I sit on the executive committee of that forum. The MET, medical education and training, unit of the HSE is working closely with the forum to try to address all of the issues that Deputy Mitchell O'Connor has just described. Something which underpins all of that is the Fottrell report, which made a recommendation of employing 725 doctors per year, based on the calculation that this is what is required for a modern health service. The Fottrell report recommends that we educate and graduate 700 doctors per annum and that we then create the capacity in the hospital system and in general practice to allow them to become specialists. The third step is that the system creates the permanent posts to take those people into the health service in Ireland. That is the principle on which both the MET unit and the Forum of Irish Medical Postgraduate Training Bodies are working.

In terms of clarity about the training journey, that is something that the trainees constantly raise and it is a very reasonable expectation. In that context, we are trying to incorporate as many posts into training rotations as possible and to have certainty about the duration of the training rotations. It is important to note that employment contracts are for six months or one year but training agreements, when a doctor is successful in getting onto a training programme, range from two to six years, depending on the specific programme. The training body is not in a position to give a contract of employment -----

Colm Burke (Fine Gael)
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Why not? Why can the training bodies not -----

Jerry Buttimer (Cork South Central, Fine Gael)
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Sorry, Senator Burke, please allow the witness to continue. I will call Senator Burke again in due course.

Professor Eilis McGovern:

I am very keen to answer the question. The training bodies select doctors for training and give them training agreements, which are signed by both parties, for between two and six years, depending on the specific programme. The training programme consists of placements in SHO or registrar posts in hospitals. That contract of employment rests with the employer - either the HSE or a HSE-funded voluntary hospital, for example. They are two separate processes and unfortunately it is not possible to give somebody a contract of employment for more than a year because the NCHD contract, which is agreed with the IMO, is for a maximum of one year. Mr. Condon might confirm that I am correct.

Mr. Andrew Condon:

The core issue, as we have discussed, is to address the employment contract because an NCHD can have certainty regarding where his or her training is going to be delivered via a robust training agreement. Therefore, the question is why they have to break employment every six months and that will be addressed by the hospital groups. At the moment we have approximately 45% of our NCHDs working for the HSE, with the remainder working in HSE-funded agencies. By definition, the health service is currently delivered by that mosaic of HSE and HSE-funded entities. When we move to the full iteration of hospital groups there will be changes to the employment arrangements.

In response to Deputy Mitchell O'Connor, we had 513 interns a few years ago, 580 this year and will have 630 this July. We will have 740 in 2014. In the space of a few years, the number of intern places has gone up by more than 200. The HSE has done that without additional funding and without changes in the numbers it can employ. It has made other changes to accommodate those people. That gives the Deputy a concrete example of the changes that are happening.

Mr. Barry O'Brien:

As Professor McGovern said, the committee is raising an issue which is of concern to us as the statutory body tasked with the provision of health care. However, it must be put in context to bring some balance to our discussions. In the last five years, over 10,000 people have been extracted from the overall employment ceiling for the health services and the budget has been reduced by €3.5 billion. At the same time, we have increased our employment of consultants by 500 and also increased our employment of NCHDs. In response to Deputy Mitchell O'Connor's comments about paying peanuts, the average cost of medical personnel in the Irish public health system is €131,000. The next nearest cost in the payroll is €64,000 for a nurse. Below that, every other employee, on average, costs less than €55,000. Therefore, to suggest that we are not paying an appropriate rate, comparable internationally, is -----

Mr. Barry O'Brien:

----- unfair.

To be fair, there is a bigger context for where we are going on this. Again, there is the training of doctors and the contractual employment of doctors. Hospital groups and subsequently, in three or four years, hospital trusts, will become individual employers. There will not be six-month employment contracts then. That matter will be resolved.

Jerry Buttimer (Cork South Central, Fine Gael)
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I ask the witnesses to address Senator Burke's comments regarding the working conditions, particularly the length of the working day for NCHDs. I have had the parents of junior doctors come to my office to voice serious concerns about the impact of the working conditions on the physical and mental health of their offspring. The doctors themselves are afraid they will make mistakes because of tiredness. In one case, a woman in Cork came to me whose son was working as a junior doctor in a hospital, which I will not name. Such was her concern that she sent him to Dublin to see if he was okay. He had worked six 12-hour shifts in a row. We have had the IMO before this committee, as well as Dr. Mark Murphy, who spoke on behalf of the NCHDs, voicing serious concerns in this regard. These concerns are legitimate because, as Deputy Ó Caoláin said, we put our trust in these people but their competence must be compromised if they are working for 12 hours with no rest. In that context, is our system safe and fit for purpose?

Mr. Barry O'Brien:

What we are committed to is delivering a quality health service. We have a group in place which has issued clear instructions and directions to each location to meet maximum working times on a weekly and daily basis. That is now being implemented.

We have further committed through Government to the European Commission that we will have EWTD compliance by the end of 2014 and we have set out a proposal in a set of plans of how we will achieve that.

Professor Eilis McGovern:

I refer again to training. We are working with the training bodies on more clarity about the training journey, making it shorter and trying to encourage them to have a single specialty training duration, which is not divided into basic and higher but to have seamless training in order that people have certainty for even longer. For example, anaesthesia and surgery both have seamless training programmes. In anaesthetics, it is a six-year programme. If people are successful in getting onto that programme, they will get a six-year training agreement and as long as they reach their milestones, pass their examinations, etc., at the end of six years, they will be recommended to the Medical Council for entry onto the specialist register. People are voting with their feet. Anaesthesia is an attractive training programme now. Other training programmes are recognising that one of the benefits of change is that it brings others along. These two specialties have shortened their programmes by one year as part of that process.

Our junior doctors feel isolated and uninformed. The MET unit will visit all six medical schools to meet the final year medical students for an information session about the intern year and then we will meet all the interns in those locations to talk to them about training opportunities. In September, the forum will have a national training day to which all trainees are invited and all the training bodies will provide separate opportunities for junior doctors to talk to specialists in the area in which they are interested. We have asked that all the training bodies have trainees included on all their important committees in order that the trainees can have a say in how the training is delivered. We have requested that clinical programmes incorporate trainees into their committees in order that the trainees again have an input into how the health service will be delivered in the future. We have asked the training bodies to do exit interviews with those who leave training. Up until now, we have just collected the numbers to establish the attrition rate for each training body but we have asked them to interview the trainees in order that they can give us information about why they are leaving. We can then try to identify where we can make improvements.

The final piece of the jigsaw is longer term medical manpower planning. That function has been added to the remit of the MET unit and we will work with all the stakeholders to come up with a medical manpower plan for the health service that, we hope, will give further clarity to trainees in terms of where the opportunities will be in future.

Dr. Ciaran Browne:

Senator Burke referred to the initial India and Pakistan cohort and the way they were recruited two years ago. It is important to acknowledge there has been a positive contribution by the Indian and Pakistani doctors but we met with a representative group of those doctors, which comprised doctors from sites all over the country working at various levels in different specialties to see how the HSE could better facilitate their general registration with the Medical Council. None of the issues raised by the Senator were among those put on the table by them to cause them not to undertake the registration process. This was a representative group from different parts of the country and they did not highlight the issue he raised. Their significant issue was more to do with how the registration process was set up for them to undertake it.

Colm Burke (Fine Gael)
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Why can the training bodies not do two-year contracts? Why can two hospitals, say in Cork and Waterford, together with the training body not sign one contract for two years? That is being done in the UK. I accept there are different pay structures and, technically, there are two employers but surely in this day and age there is nothing to prevent two hospitals from coming together with the training body to offer a two-year contract for a training programme at two locations.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The critical date is 8 July. We cannot continue to meet on a regular basis but I would like the committee to receive an updated snapshot, given only four weeks remain, to give us a sense of what is happening. This is not for our entertainment. People engage with us on a continuous basis and we want to be in a position to assure them, as the representatives are endeavouring to assure us, although not as successfully as they might like. Let us help each other with this. If they could provide the clerk to the committee with an update in order that members can be informed about where we are at as we approach the remaining four weeks leading up to 8 July, that would be helpful.

Mr. Barry O'Brien:

We can provide that. That is not problem.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. O'Brien, Professor McGovern, Mr. Condon and Dr. Browne for attending. I also thank the members because we had an early start. I would also like to acknowledge the presence of Mr. Brian O'Toole from the HSE in the public Gallery. Our concerns are based on a genuine expression of opinion given to us by those working in hospitals and members of the IMO and based on our own experience.