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.

Also under the public service sustainability agreement, the IMO, the Irish Nurses and Midwives Organisation, INMO, and the Services Industrial Professional and Technical Union, SIPTU, have confirmed their co-operation with the commencement of task reallocation from doctors to nurses, in specified areas, namely phlebotomy, cannulation, first dose medication and delegated discharge. They have committed to further negotiations on other changes to health care delivery to achieve EWTD compliance.

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.