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The difficulty filling vacant posts across all disciplines in the health service has been just one of the damaging legacies brought by the recent recession.
However, while we keep hearing about the ‘recovery’, the consultant recruitment crisis shows no sign of abating. It is estimated currently that over 400 approved hospital consultant posts are either vacant or filled on a temporary/agency basis.
The 30 per cent pay cut for new entrants, implemented in 2012, was blamed by medical representative bodies for the lack of badly-needed appointments to key posts in hospitals across the country. Although the pay cut has been partly reversed, the recruitment of consultants continues to be problematic for various reasons. In addition, the IHCA recently expressed serious concern that an increasing number of temporary consultant posts are being filled by doctors who are not eligible to be on the Medical Council’s Specialist Register.
Another issue, identified by those involved in recruitment, are the new requirements by the HSE for the processing of new consultant posts. In July 2016, the HSE’s Acute Hospitals Division (AHD) issued the instruction that Executive pre-approval for funding was necessary in order for posts to be forwarded to the Consultant Application Advisory Committee (CAAC) for consideration. The role of the CAAC is to provide independent and objective advice to the HSE on applications for consultants and qualifications for consultant posts. Membership of the Committee includes an independent chair, senior HSE planning officials, and consultant representatives.
The CAAC had immediate concerns about the new instruction issued by the HSE. At the CAAC meeting in September 2016, the minutes of which were seen by the Medical Independent (MI), a list was circulated of posts approved at the previous meeting and their status regarding funding approval.
“Posts which were recommended for approval at that time but now found to be lacking funding approval will be paused, and the letters of approval withheld until funding is confirmed,” according to the minutes of the meeting.
At the next CAAC meeting in October, it was stated the new requirement on needing AHD confirmation of funding for posts has further delayed the issuing of letters of approval.
The Committee members raised concerns that there may be a perception the CAAC is the source of the delays.
It was agreed, in order to mitigate this perception, that the Chair of the Committee Mr Brian Purcell write to the IMO, IHCA and the Forum of Irish Postgraduate Bodies, informing them of the new requirement.
The matter was also discussed at the November and December meetings of the CAAC.
In December, CAAC member Dr Colm Henry updated the Committee about a meeting with the AHD regarding the Committee’s concerns on the impact of the AHD Pay Bill Management Committee on the CAAC processes.
Dr Henry advised that the AHD Committee had no intention to replicate the work of the CAAC and that its function was to seek assurance that funding had been secured for posts.
A meeting was arranged for 20 December with the AHD Committee to discuss the CAAC ’s concerns around the new AHD funding process with regard to all additional and replacement consultant posts.
Fall in applications/approvals
Yet in spite of the CAAC’s remonstrations, the issue has still not been resolved.
Figures provided to MI by the HSE show the scale of the impact of the new requirement.
The total number of applications considered by the CAAC in 2016 was 238, with 175 recommended for approval during the year.
Between January and June 2016, a total of 140 applications were considered by the CAAC but, in contrast, between January and June 2017, a total of 77 applications were considered by the Committee, a reduction of almost 50 per cent.
The number of approvals is also down by a similar extent. During the first six months of 2016, a total of 126 applications were recommended for approval. The corresponding figure this year is 62.
The Committee continues to express serious apprehension about the trend. In the March 2017 meeting of the CAAC, Committee members voiced concerns around the “very low volume of applications received since the introduction of the new requirement, and the implications for members of monthly meetings with very small volumes of business transacted,” according to meeting minutes seen by MI.
It was agreed that the CAAC Chair would write to the HSE Director General Mr Tony O’Brien to raise these concerns and the implications for services and patient safety.
At the April meeting of the CAAC, a discussion took place regarding the letter issued to Mr O’Brien.
“A discussion ensued regarding the possibility of a streamlining process, whereby the Paybill Management Committee provide a projected outlook of applications received monthly to the CAAC,” according to the April minutes.
“The Committee agreed that further correspondence should issue from the Chair and [be] circulated to members for any additional comments or views prior to sending to the Director General.”
At the May CAAC meeting, it was agreed that the “marked decline in applications when compared to the same period in 2016” would be monitored closely, with members being advised of the number of potential applications to be considered in advance of each meeting.
Dr Peadar Gilligan, Consultant in Emergency Medicine in Beaumont Hospital, Dublin, sits on the CAAC as one of the IMO’s representatives. He told MI the current situation is very concerning.
“It is a huge issue, particularly in the context of a country that is struggling to fill senior medical physicians in acute hospitals across the country,” Dr Gilligan said.
“Essentially, this has created yet another obstruction to the recruitment of consultants by hospitals by virtue of the fact that they have to have dedicated funding in place before they can make the application. So it is another delay in the process. We haven’t been given a particular rationale for it. I suppose you can understand and appreciate that they would want to know in the event of an application being ratified that there was going to be funding available to appoint the consultant. But while we can understand that rationale, it hadn’t been a requirement previously. And in the face of challenges in recruitment and retention already, it does seem a very odd thing to do, to make the process even more onerous for hiring consultants.”
Dr Gilligan said that the HSE’s Towards Successful Consultant Recruitment report (see panel) was welcomed by the CAAC. However, from the IMO’s perspective, he said that the report is severely limited by its failure to address consultant remuneration. This limitation, he pointed out, was due to the instruction from the HSE Director General.
“Clearly, it is not addressing the major issue, or one of the major issues, of terms and conditions for consultants,” Dr Gilligan said.
“And until that is addressed, we are going to have an ongoing recruitment and retention issue.”
Additional reporting by Niamh Cahill
A forensic look at the recruitment process
Earlier this year, the HSE published a document titled Towards Successful Consultant Recruitment. The working group that developed the document, which was chaired by Prof Frank Keane, identified a number of problems with the recruitment process relating to the CAAC and the health service as a whole.
The group noted the need for formal and regular review of CAAC membership, participation, standing orders and output to ensure accountability and assurance that appropriate governance arrangements were in place. It recommended that existing standing orders be reviewed and agreed that the CAAC output form part of standard HSE performance reporting.
The report also stated that the assessment of applications by the HSE’s National Doctors Training and Planning (NDTP) unit, clinical/group leads/nominees of the CAAC and the HSE Acute Hospital and Mental Health Divisions are not standardised, nor is feedback consistent.
This results in delays in the consideration of applications and a lack of clarity regarding the rationale for decisions at this level. The report recommended that applications be submitted to the NDTP once reviewed by the relevant clinical programme, and that a standard feedback form should be completed as part of this process for consideration by the CAAC.
This process should ensure that the relevant clinical programme, as well as advising the hospital in question, can advise the CAAC directly of any national or strategic issues arising in relation to a particular post. This process should take no more than three weeks, according to the document.
The group also noted the CAAC is not currently required to conform to any particular time scale for the consideration of applications. This means that there is a lack of clarity as to timelines for progress of applications/resolution of issues.
As a result, it recommended that the CAAC considers and makes a decision to approve, refer for resubmission or reject an application within eight weeks of the closing date for receipt of appropriately-completed applications by the NDTP.
According to the document, it should also terminate consideration of applications where no response has been received from the applicant hospital to queries after three months and inform the relevant site of the decision.
Also, the HSE is not currently required to conform to any particular time scale regarding a decision on a CAAC recommendation, which has the potential to delay issue of letters of approval and progress of approved posts.
To address this problem, the document suggested the HSE should make a decision regarding posts recommended for approval by the CAAC and authorise the issue of a letter of approval within one week of receipt from the NDTP.