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The new consultant contract six months on

By David Lynch - 11th Sep 2023

consultant

Recent statistics on consultant recruitment have provided insight and context on how the new public-only consultant contract is being received. David Lynch reports 

Over 400 doctors had signed up to the new public-only consultant contract 2023 (POCC23) by the end of August, new figures reveal.

It is now six months since the contract commenced roll-out. Both the HSE and doctors have reported a “steady” increase in the uptake on a weekly basis.

The POCC23 became operational on 8 March, after more than a year of debate, discussion, and stop-start negotiation.

Upon its commencement, Minister for Health Stephen Donnelly described the contract as “important… and attractive”. Doctors themselves appeared less sure. In March, a IHCA survey of its membership showed 73 per cent were “not confident” the new contract would address the consultant recruitment and retention crisis. In the same month, the results of an IMO ballot revealed 57 per cent of current contract holders would not change contract, while 64 per cent of NCHDs said they would not take up the new contract.  

The leadership of both representative bodies were cautious when consultants across the country were first presented with details about the POCC23. Speaking in February to the Medical Independent (MI), IHCA President Prof Robert Landers said the contract would lead to “gradual change, not a big bang”. In April, former IMO President Dr Clive Kilgallen told MI that it would be at least a year before the effectiveness, or otherwise, of the new contract could be judged.

Now we have reached the six-month mark and MI has received a series of HSE figures and responses to Freedom of Information requests that give some context to how the contract has been received at this juncture.

As first reported in MI, 195 consultants had signed up to the POCC23 by 19 July.

Some 125 of these were existing consultants who had switched, with the other 70 being new entrants. 

By 29 August those numbers had more than doubled to 419 consultants who had signed the POCC23, according to figures provided to this newspaper. Some 294 of these were existing consultants who had changed contract and 125 were new contract holders.

Included in these numbers are the consultants in public health medicine who are currently being appointed following the 2021 agreement between the IMO and the Department of Health to recruit 84 public health consultants by the end of this year.

As of 18 August, 34 public health consultant posts were filled during phase one of the recruitment process. Phase two was ongoing, with 10 consultants “onboarded” and a further 20 at varying degrees of progress (see news story, p8). All of these public health consultants are employed under the POCC23.

“Recruitment is continuing apace, albeit with a few delays here and there,” Dr Anne Dee, Chair of the IMO public health committee, told MI.

“The process has not been an easy one, and the application process is in itself stressful, as indeed is the amount of change taking place [in public health].”

Steady

According to separate HSE figures provided to MI, there were 3,984 consultants employed by the HSE as of the 10 July. This was an increase from 3,571 at the end of 2022 (see panel on p5).

A HSE spokesperson said there has been “a steady increase week on week” across the health service with consultants signing up to the POCC23.

There has been “considerable interest in consultants getting details of the new contract”, said the spokesperson. “The new contract has significant benefits for the health services in terms of the flexibilities contained therein and also an attractive remuneration package for the individuals.”

The spokesperson also noted that the HSE had begun an international marketing campaign to recruit consultants to work in Ireland. This campaign was first launched in the UK and Australia in June using a combination of the medical trade press and digital advertising and social media posts to target doctors originally from Ireland or international doctors with an interest in working here.

The HSE said information regarding the effectiveness of this campaign will be available in the coming months.

Cumbersome

From the doctors’ perspective, the IMO noted that the roll-out of the POCC23 is still in its early stages. “In reality, we are not really six months since the introduction, we are six months since the announcement,” Prof Matthew Sadlier, Chair of the IMO consultant committee, told MI.

Prof Sadlier, who is a Consultant Psychiatrist, noted that some clarifications regarding aspects of the contract were not issued until the end of April. “So the reality is, the actual process of people being invited to transfer over didn’t really start until May, June.”

He said feedback from IMO members indicated “there is definitely a steady stream of consultants looking to switch over [to the POCC23]. But, I expect that we won’t get a real overall idea about that until December.”

Prof Sadlier revealed some consultants and clinical directors had described the changing of contract “as a quite cumbersome process”, which takes six-to-eight weeks to complete.

This length is due to several factors, said Prof Sadlier, including the fact that each contract change is on an individual basis, with unique work plans to discuss.

He noted many consultant work plans have “evolved” over time. “Covid caused a big change to the system,” Prof Sadlier added. In his own case, “what I do on a day-to-day basis is quite different than my original work plan.”

He continued: “One of the challenges is going through the work plan and agreeing the individually specific work plan… with their clinical directors and their HR [human resources] managers, that is an individual thing and that will take time.”

Delay

Could the process be streamlined?

“Medical HR departments are hugely overrun, compared to every other HR department in a hospital,” he said, highlighting the workload caused by NCHD rotation every six months as a factor.

“I actually suspect what will happen, in the months between now and maybe November, we might see a bit of a rapid progress [of consultants signing the POCC23], but then we will come up to December and January and then every HR [department] in every hospital is 100 per cent focused on NCHD changeover… it’s a huge amount of work.”

On the consultant side, Prof Sadlier said that each consultant wants to ensure that “every ‘i’ is doted and ‘t’ crossed” in their individual contract, often by seeking advice from their representative body. 

“So, I can’t see the process streamlining massively. Possibly down to four-to-six weeks maybe.”

Given the protracted nature of the process, the IMO is “disappointed” that the HSE said “they are going to only pay consultants the increased salary only by the time they start the contract, rather than the time they applied to move to the
new contract”.

Prof Sadlier added consultants should not be “punished” because of the time it takes to switch over.

By the end of 2023, when “significant numbers” of consultants have moved to the POCC23, “it will be interesting to look at the breakdown of geography and specialty,” he commented.

Prof Sadlier said he had not received concerns about the contract from any specialty in particular. “Really, by December, I suspect we will be able to do a decent analysis and look to ironing out some of the problems.”

Sláintecare

The POCC23 is regarded by Government as fundamental to the implementation
of Sláintecare.

Progress with the contract was raised at the Sláintecare programme board in June. According to the minutes, “members discussed the current take-up levels among new and transferring consultants as well as those registered.”

A spokesperson for the board told MI that members regard the over 400 consultants who have signed up “as a positive step in terms of the Sláintecare programme reforms”. 

“We are optimistic that the numbers on the POCC23 will continue to rise over time. It is important to highlight that the hiring process of new consultants can take up to nine months.” 

Echoing comments made by Prof Sadlier, the board’s spokesperson said the process of switching to the new contract takes some time “as a consultant’s work plan under the contract” must be agreed in advance with the employer. 

The spokesperson added the contract will involve a “significant expansion” in consultant availability and the provision of consultant-delivered care and consultant decision-making over an extended day: Monday-Friday (8am-10pm) and on Saturdays (8am-6pm).

“The contract will ensure that we have more senior decision-makers in our hospitals out-of-hours and at weekends,” they said. This will “benefit public patients” with the “key terms and principles of the contract supporting and enabling Sláintecare”. 

Reluctance

In the IMO’s ballot results released in March, the concerns raised included rostering, location and sufficient medical and other staff being available.

“When you look at the reasons behind that, interestingly the actual salary level was not a factor,” said Prof Sadlier. “In fairness, doctors seemed to be relatively happy with the salary number. But, there were the issues about structured work on a Saturday, the issues about location and other issues.”

Prof Sadlier said concerns remain and this is contributing to “reticence” from some consultants to take up the POCC23.

“I know some doctors are concerned that the HSE won’t be able to deliver on their promises,” said Prof Sadlier, “so they are cautious about moving onto the new contract on that basis.”

He said one concern is the removal of private practice from public hospitals, with consultants questioning where “hospitals will get their funding that they currently get from health insurance”. Some consultants are concerned that they could be “caught in no-man’s land” under the terms of the new contract.

Other consultants have suggested there might not be sufficient consultants employed by the health service to cover the expansion in the shift to a six-day working week.

“If you are in a department with seven consultants… you don’t want to be the only consultant who signed over to work on a Saturday and then they open up a six-day department and you are now working every Saturday. They are the sort of concerns that we are getting.”

The IHCA had not responded to queries on the new contract by the time of going to press.

In April Prof Gabrielle Colleran, who was part of the IHCA negotiation team, wrote in MI that “the proof of the pudding is in the implementation, so to speak”.

“As the contract rolls out, we’ll need some of that Covid-style agility and flexibility to identify and manage any unintended consequences that could negatively impact the end goal of recruitment and retention,” she outlined in her piece.

A specialist concern

There were 109 consultants employed by the HSE who were not on the Medical Council’s specialist register as of the end of June, according to figures provided to the Medical Independent (MI). This figure, which was extracted from DIME [Doctors Integrated Management E-system].

Saolta University Health Care Group was the Hospital Group with the highest number of consultants not on the specialist division (29). It was followed by South/South West Hospital Group with 19, then Dublin Midlands Hospitals Group and Ireland East Hospital Group with 12 each.

In January, MI reported there were 101 consultants employed by the HSE who were not on the specialist register.

As previously reported in this newspaper, at the April 2021 meeting of the HSE’s people and culture committee, the employment of consultants not on the specialist register was raised. The committee considered the issue to be “very serious”.

The IHCA has also drawn repeated attention to the problem. In the Association’s recent pre-Budget submission, the situation was again highlighted.

“Over a hundred doctors who are not on the Medical Council specialist register have been appointed to hospital consultant posts… in breach of the Medical Practitioners Act, 2007, and the HSE’s recruitment rules,” according to the IHCA’s document.

“The HSE seems to intend to continue this practice as it provides in a recent circular for the appointment of non-specialists in consultant posts in its guidance to hospitals under the 2023 contract.”

According to the Association, this is an “indictment of a failed HSE policy and is a clear breach of the 2023 consultant contract, which stipulates the contract is conditional on the consultant being registered on the specialist division”.

MI asked the HSE about the future appointment of consultants not on the specialist register under the new contract.

The spokesperson said that the HSE makes “every conceivable effort” to fill consultant posts with doctors who hold specialist registration. However, they added “it is not always possible to do so”.

The spokesperson said that “the escalation protocol” ensures that in “the limited circumstances where a doctor on the general register is appointed to a consultant role, that supervision and risk mitigation factors are in place to ensure the safety of service provision”.

The memo accompanying the protocol stipulates that consultants not registered on the specialist division are not permitted to be appointed to a consultant post without reference to the protocol and the prior written approval of the HSE Chief Operations Officer. The protocol was introduced in September 2018. 

“It confirms the health service obligations to ensure that any consultant appointed in the public health service holds the qualifications required to work safely at consultant level and acknowledges that any breaches of the employer’s regulatory requirements have significant implications for the organised and safe delivery of services,” said the HSE spokesperson.

Consultant numbers continue to grow

The HSE provided detailed figures to the Medical Independent regarding consultants working in the health service and consultant vacancies in June. At the end of that month, there were 3,766 consultant posts filled across the HSE system. This represented an increase of 195 on the total figure of 3,571 at the end of last year.

At the end of June, there were a further 40 posts defined by the HSE as ‘vacant-future start date’. The HSE defined this as when “recruitment has concluded and a successful candidate has been appointed with their agreed start date in the future”.

There were 488 consultant posts vacant, according to the figures. A further 12 posts were described as ‘unknown status’.

The Hospital Group with the highest number of vacant positions was South/South West Hospital Group with 89 (574 filled). It was followed by Ireland East Hospital Group with 83 vacancies (618 filled) and Saolta University Health Care Group with
50 (499 filled).

The IMO and IHCA have previously stated there are over 800 consultant posts unfilled on a permanent basis. The HSE figures designate posts filled by temporary or locum doctors as ‘filled’ and these posts are not included in the number of vacancies.

“We are short a further 2,000 consultants based on population at the moment, so the scale of the challenge is clear,” Prof Matthew Sadlier, Chair of the IMO consultant committee, said last month. “We remain very concerned at the growing waiting lists and the intolerable conditions for patients and staff within our services where resources are stretched and there are insufficient staff across all grades.”

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