Dr. Peadar Gilligan:

The IMO thanks the Chairman and members of the Joint Committee on Health for the invitation to discuss recent media reports which suggest that up to 650 doctors are employed as consultants without being registered on the specialist division of the register of medical practitioners. The figures in circulation from the Medical Council are self-declaration figures from 2015 of those who describe themselves as hospital consultants. The figures would also include some people who are abroad, are in training, have not been grandfathered to the specialist register, are in locum positions, are in acting-up roles and are temporary consultants.

Ireland is a challenging place to work as a consultant. Significant capacity issues impact on a consultant's ability to provide safe quality care to patients. According to the health service capacity review, we require an additional 1,260 acute beds immediately and will likely require up to 7,000 hospital beds by 2031 in view of the current extent and pace of investment and reform. Bed occupancy rates in Irish hospitals have risen to an average of 97% and sit even higher, at an average of 104%, in model 4 hospitals, well above internationally recognised safe occupancy rates of 85%. The HSE full capacity protocol is now the norm, having been implemented on hundreds of occasions in 2017 in our major hospitals in Waterford, south Tipperary, Galway , Limerick, Cork and Beaumont. Constant overcrowding, cancellation of lists and rolling theatre closures impact not only on patient care, but also on the ability of trainee specialists to maintain and develop their skills.

Hospital doctors in our health system work excessive hours and show high levels of stress and burnout. The Royal College of Surgeons in Ireland's A National Study of Wellbeing of Hospital Doctors in Ireland showed that, on average, hospital doctors work 57 hours per week, and one in three shows symptoms of burnout. Antagonism of consultants by employers, politicians and the media adds to the poor morale of doctors. Reluctance on behalf of the Government to engage with doctors in a meaningful way and political interference in contractual disputes reflect the inadequate value our politicians place in the medical profession.

I would also like to take this opportunity to say a few words on specialist registration and the industrial relations environment. Doctors who have achieved specialist registration may practise independently without supervision and may present themselves as specialists. Attaining such registration is, and should be, the goal for trainee doctors in the health system. It should be a sine qua nonfor appointment to a consultant post that one should be so registered. We have no doubt but that among this group of consultants who do not currently have specialist registration are many fine and committed doctors who do their utmost to deliver patient care in the most trying of circumstances, in a system starved of capacity and resources and where crisis management appears to be the default setting. Nonetheless, the practice of appointing doctors who do not hold the correct registration to consultant posts is inappropriate and should cease. Patients who require specialist care should receive it from a registered specialist. There are potentially significant indemnity issues that arise from non-specialist doctors working as consultants in an under-resourced and overstretched health service.

Consultant-delivered care, it is worth reminding ourselves, is associated with better clinical outcomes for patients, increased patient safety and more efficient use of healthcare resources. However, we strongly contend that this present issue is just part of a wider problem, one which has culminated in the Irish public health service not being the employer of choice for medical personnel, and the profoundly concerning circumstance in which consultant posts are advertised but not filled. This was the case with 22 of 84 closed consultant recruitment campaigns in 2016.

Why has this come about? It is important to go back to basics. The current consultant contract, to which I have already alluded, contains a series of pay promises that were not honoured and that are now the subject of costly litigation. No other group of public servants who had signed contracts in good faith would ever be treated in this fashion. Furthermore, consultant salaries were unilaterally and unfairly reduced by 30% in 2012. Again, no other group of public servants was singled out and treated in this fashion. While the work of the IMO has ameliorated much of the effects of this cut, the price that we had to pay was a longer pay scale with lower starting and finishing points and very significant reduction in pensions for consultants appointed since 2012. Less well remembered from that time were attempts by the then Minister for Health to introduce a consultant level 1 role that would sit below the existing consultant cohort. This strain of thinking, viewing consultants not as a valuable resource but as an obstacle to be overcome, continues to influence and infect policy-making today. The health service, however, suffered dreadful reputational damage. Why would highly trained specialists who operate in a global market work in a system that could dismiss their contractual entitlements in such an offhand fashion? It is for this very reason that 450 consultant posts, posts for which there once would have been fierce competition, now lie vacant or are filled on a temporary basis only. When taken in the context of our comparative shortage of doctors, we have 2.9 practising physicians per 100,000 population, compared to an EU average of 3.4 per 100,000 population. This should be profoundly troubling for any party interested in health service delivery. In a recent IMO survey, over one quarter of consultants indicated that they were considering taking up a post abroad in the foreseeable future, while over 70% believe that their remuneration, training supports and access to colleagues would be improved by moving abroad. In summary, we have a public health system which struggles to recruit doctors into consultant posts and which struggles increasingly to retain those doctors once appointed.

This is the backdrop against which non-specialists are appointed to specialist posts. Long hours, poor access to supports and inability to deliver the type of care for which consultants have trained have served to turn a generation of talented medics off the idea of working in the Irish public health service. We cannot afford to alienate these doctors. This is because there are approximately 2,700 consultants in the public system, when the Report of the National Task Force on Medical Staffing recommended a figure of 4,400. However, patients must be seen, and the service requires that consultant appointments be made.

It must never be the responsibility of the patient to determine whether their specialist is in fact a specialist; that is the responsibility of the employer. Patients must have confidence that their consultant is a specialist and that the care they receive is of the appropriate standard.

I will finish with a quote from the consultant survey that the Irish Medical Organisation, IMO, conducted last year. We gave respondents the opportunity to provide us with a comment. Many of those comments were eye-opening, but the one that struck me most was provided by a recently appointed consultant, who wrote:

I would resign now, except that I have to pay a mortgage and provide for my family. I’m sorry I came back.

The blocks to specialist recruitment to consultant posts must be addressed as a matter of urgency.