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Inside Ireland’s deepening consultant crisis

The frustration was very palpable. People got very emotional when they were talking about how it made them feel. It can’t go on like this.”

Consultant Gastroenterologist in Tallaght University Hospital Dr Anthony O’Connor is talking about the recent meeting held by the IMO for consultants appointed since 2012 and SpRs. The subject under discussion at the meeting, which took place on 2 July in the Crowne Plaza in Santry, was the infamous ‘new-entrant’ salary cut. The meeting was the first of the Organisation’s ‘Fight for Fairness’ campaign.

Now that the medical unions have reached a settlement over the failure to honour the 2008 consultant contract (see panel), the salary cut imposed in 2012 is seen as the number-one issue that needs to be tackled to help solve the consultant recruitment and retention crisis besetting the health service.

Agreement reached after years
of frustration

David Lynch

After many years of anger and frustration on the part of consultants and their representative bodies, legal proceedings (in relation to a decision by the Government in April 2009 not to pay the final phase of increases provided under the terms of the 2008 contract) eventually reached the High Court last month.

However, very quickly, a settlement was reached. 

There were 10 cases taken by consultants before the High Court. These were lead cases and were representative of some 700 similar cases in the system, with a potential further 2,000 cases predicted, with similar grounds for initiating proceedings.

According to the Minister for Health Simon Harris and Minister for Finance and Public Expenditure and Reform, Paschal Donohoe, initial estimates of liability for arrears arising from the cases for the State was assessed at up to €700 million. The estimated costs which will arise as a result of the settlement reached last month are €182 million for arrears, and ongoing costs of €62 million per annum from 2019, backdated to the date of settlement in June 2018.  The arrears will be phased over 2019 and 2020.

While criticising what they call the “discrimination” that remains with new-entrant consultants (see main article), both the IHCA and the IMO welcomed aspects of the settlement.

“[I am] disappointed that we had to go through a process of litigation against the State to have our contract honoured,” IMO President and Consultant in Emergency Medicine Dr Peadar Gilligan tells the Medical Independent (MI). “I am disappointed that it took that length of time to resolve an issue that was clearly a breach of contract. I am extremely disappointed that people who have taken contracts since October 2012, that their particular issue was not addressed within the settlement.”

Looking at the positive results of the settlement, Dr Gilligan says “it basically means that over a period of time, between the FEMPI reversal and the actual court settlement, consultants will be paid to the level they are actually contractually entitled to be. And that, I suppose, is a relief to us.

“But it is extraordinary, as I said, that the State would feel the need to subject senior doctors in the hospital system to the court system to have their contractual rights honoured, and it certainly doesn’t auger well for relations between the Department of Health, Department of Finance, the Department of Public Expenditure and Reform, and the health service in general.”

IHCA Secretary General Mr Martin Varley similarly raises the Association’s concerns regarding outstanding issues with new entrants. “While the High Court settlement on 15 June is a first significant step in restoring trust between consultants and health sector employers,” Mr Varley tells MI, “the IHCA has highlighted and repeatedly stressed, including in the High Court negotiations, that it is essential to end the discrimination against new-entrant consultants without delay, as Ireland is no longer competitive in the global marketplace for talented doctors.”

“People are extremely annoyed about it,” according to Dr O’Connor.

“It is just not fair. People in many cases are doing more work, but certainly no less, than their colleagues and there is a massive differential in pay, in access to private work, things like that. It is unsustainable. ”

President of the IMO Dr Peadar Gilligan tells this newspaper that new-entrant pay is now the biggest issue that has to be addressed to improve consultant recruitment.

“We absolutely have no doubt now that this is going to be the main issue that is going to prevent us from getting the number of specialists working in the system that we require,” says Dr Gilligan.

 “And until it is addressed, we are going to have an ongoing challenge in recruitment and retention.”

The Secretary General of the IHCA, Mr Martin Varley, is of a similar view. 

 “This is the primary reason that the Irish health service is no longer competitive in recruiting and retaining new consultants in the English-speaking market, where specialists are highly sought after,” according to Mr Varley. 

The cut

During the 2011 election campaign, the soon-to-be Minister for Health Dr James Reilly had promised to impose reduced salaries on consultants. When the new Government was formed, negotiations began as part of the Public Service Agreement about remuneration and working arrangements in light of the economic recession.  Pay increases for consultants as part of the recently signed contract had already been withheld by the previous Government, and salaries were reduced as part of FEMPI [Financial Emergency Measures in the Public Interest] legislation.

Any hope that relations would improve were dashed with the announcement of the 30 per cent cut to be imposed on newly-appointed consultants in October 2012. Neither the IMO nor the IHCA were informed of the decision to cut the salary before it was announced on radio.

Following publication of the MacCraith Review into medical training and career structures, the IMO met with health service management several times in June, July and August 2014, and ultimately decided to seek the intervention of the Labour Relations Commission (LRC).

With the assistance of the LRC, proposals were drawn-up and put to a ballot of NCHDs and newly-appointed consultant members of the IMO and were ultimately rejected in October 2014.

As a consequence, the IMO wrote to the HSE, advising that feedback received suggested that the length of the incremental scale (12 points at that time) was a particular problem that had been identified from anecdotal evidence during the voting process.

A revised proposal was subsequently agreed that reduced the incremental journey time to nine points, with the provision to enter as high as point six.

The nine-point scale was intended to introduce parity over time. The scales agreed for the Type A contract had top points of €178,000 for pre-October 2012 entrants and €175,000 for post-October 2012 entrants.

However, the IHCA said the deal would perpetuate the pay discrimination against new entrants, stating at the time that the proposals represented a 20 per cent salary cut for new-entrant consultants, on a like-for-like basis after four years in-post, and failed to deliver full parity even after nine years.

As a result of the recent court settlement, new entrants have now fallen even further behind many of their peers in the salary scale. The IHCA estimates that recently-appointed consultants are on salaries significantly below those of their pre-October 2012 colleagues, who are currently being paid up to 57 per cent more.

Views from the ground

So what has been the effect of the cut? There are many contributing factors to the recruitment and retention crisis. It is difficult to separate the problem from the difficult working conditions in Irish hospitals, where overcrowded emergency departments and long waiting lists are prevalent.

What is beyond dispute is that there are approximately 450 approved consultant posts, a full 15 per cent of the total, which cannot be filled on a permanent basis. About half of the posts are vacant and some are filled on an agency basis. Also, a high number of consultant positions are currently being occupied by practitioners who are not on the Specialist Register.

 Whereas in the past, dozens of applications were made for advertised consultant posts, now it is common that only a few applications are received, and sometimes, none at all. According to staff turnover figures collected by the HSE for 2016, some 39 per cent of those who left consultant posts during that year resigned their positions, while 46 per cent had their contracts expire. The overall turnover rate for consultants in the HSE was 8.9 per cent last year, while the corresponding figure for NHS England was just 6.1 per cent.

There are also anecdotal reports that a growing number of consultants are leaving the public sector to work privately (see panel).

The public sector exodus

Niamh Cahill

Irish hospital consultants have commonly chosen to move from the public to the private sector for various reasons during the course of their careers.

But now, more than ever before, some of the country’s most experienced and knowledgeable consultants are leaving their posts in direct response to challenges in the public system.

Many consultants, particularly procedure-performing consultants, are increasingly frustrated with being unable to treat patients due to procedure and surgery cancellations in public hospitals.

Often, consultants do not feel supported and respected by the HSE in their roles. Because of this, they are moving to posts abroad or in the private sector, where they can work as part of a team with adequate supports.

As the medical staff recruitment and retention crisis in healthcare becomes more acute, the resignations from the public sector mean posts are being left vacant for long periods of time, as replacements are difficult to find.

This is turn means that patients are waiting longer for care due to staff shortages. 

Ireland is now at the point where 50 per cent of medical staff vacancies are the result of resignations, according to Dublin GP Dr Ray Walley.

Dr Walley criticises the Government for inaction in response to the resignations, adding that he believes hospital waiting lists will rise further as resignations continue.

Cork University Hospital (CUH) has in the last two-to-three years lost a cardiologist, respiratory medicine consultant, neurologist, pathologist and some orthopaedic surgeons and radiologists to the private sector.

Increased frustration was shown by consultants at the hospital last year, when a group campaigned to change their contract to allow them to perform off-site private work.

The consultants called for the change amid increasing difficulty in getting patients into the hospital for treatment due to elective surgery cancellations and long waiting lists.

Some consultants disagreed with the campaign and the Consultants Committee at the hospital held an extraordinary general meeting (EGM). Two consultants were successful in changing their contract.

At Cork University Maternity Hospital, there have been no new consultant posts advertised since it opened, one source told this newspaper.

Two consultant staff members at the hospital are on career break, with only one likely to return, while a replacement post has yet to be found for a consultant who left for the UK last year.

Midland Regional Hospital Mullingar has been unable to fill a vacant consultant dermatologist post since February.

Because of this, GPs in the region are being asked to direct dermatology referrals to other hospitals.

Four hospital consultants in Limerick have resigned from the public health system in the last six months.

The consultants, who are all currently practising privately, include an orthopaedic surgeon, ENT surgeon, anaesthetist and eye surgeon.

Three consultant psychiatrists in the south east recently resigned from the public health service, raising concern about the delivery of adult and child mental health services in the region.

Furthermore, the Medical Independent (MI) understands that at least four Dublin-based consultants, some operating at the Mater Hospital, have moved to the private sector in the last year. 

Doctors believe the revelation of State-sponsored ‘spying’ on consultants — to ascertain whether they were abiding with their contractual public/private mix ratio — will result in more clinicians moving into the private sector or abroad, further exacerbating the recruitment and retention crisis within the health service.

The State’s actions have not only caused consternation among the profession, but will also negatively impact the health service for years to come, doctors told this newspaper.

Mr Asam Ishtiaq, Clinical Director and Consultant Surgeon at Whitfield Clinic in Waterford, describes the spying as a “new low in industrial relations”.

“It is only going to make the relations between the HSE and consultants more fractious,” he says.

“Every employer knows how many weekly commitments their consultants have and can have very accurate monitoring of this.”

Consultant Respiratory Physician in the Bon Secours Hospital, Cork, Dr Oisin O’Connell, is part of this trend. Dr O’Connell resigned from his position as a national heart and lung transplant medical consultant a year ago to take up his current position.

“I resigned on several fronts,” according to Dr O’Connell.

“One is the discrimination against new-entrant consultants. I found myself doing an incredibly pressurised, highly-skilled job with significantly worse terms and conditions to my colleagues. That was the first thing. Then there was doing a very onerous on-call roster… the majority of consultants in the public service are working well above and beyond.”

Dr O’Connell says that the last eight consultants who have been appointed to the Bon Secours Hospital in Cork have all resigned from public service jobs.

“When morale gets shot, issues like discrimination become much more apparent. I think that is clear among the new entrants at the moment. There is a lot of anger among new-entrant consultants that they are being paid substantially less in jobs. When you are working in an extremely challenging environment, and then on top of that you get the straw breaking the camel’s back of discrimination, then you start looking at other options. I think it is what a lot of people are starting to do now. ”

Another respiratory consultant, Dr John Garvey, who is based in St Vincent’s University Hospital, Dublin, tells this newspaper that in 2015, he left Ireland for Canada, despite successfully interviewing for a consultant post in Galway University Hospital. Dr Garvey made the decision due to the length of time it took the HSE to confirm his salary. Since then, the HSE has made moves to improve the process by which consultants are appointed (see panel).

“The salary was far greater in Canada than was offered here in Ireland. The terms and conditions were far better as well. I had protected time for academic work. Lots of Irish consultants are deciding to stay abroad because the terms and conditions that are on offer here just don’t match the attractiveness of what’s on offer abroad. And one of the carrots with regard to this is salary. But the HSE and the Department of Health seem to have taken the attitude that ‘not only are we not going to try and attract you back, but we are actually going to discriminate against you and pay you far less than your colleagues who were only appointed a few years ahead of you’. People have voted with their feet and are not taking up positions in Irish hospitals as a result of this policy.”

In 2016, Dr Garvey returned to Ireland to take up a position as Consultant Respiratory Physician and Director of the Sleep Laboratory, St Vincent’s University Hospital. He says that St Vincent’s was extremely professional in attracting him back and that he made the decision because of the attractiveness of the post.

Both Dr O’Connell and Dr Garvey says that working conditions were at least as important as salary in making their decisions to leave posts.

“This isn’t so much about the salary,” says Dr Garvey, “because the salaries are relatively high, but it is about the disparity in terms of working conditions and the concept of not being treated equally in the same way.

“People are unhappy with that. And people just aren’t going to come back for jobs and accept that, if that’s the case. ”

Dr Anthony O’Connor also agrees with this assessment. He recently returned to work in the Irish health service from the UK on the understanding that the new-entrant salary issue would be resolved.

“I think the salary is a big barrier to coming back,”Dr O’Connor says.

“But I don’t know the role it plays in people going away. It probably does play a role in people going away. But I think it is a huge barrier to people actually coming back. I think people who are going away for training with the intention of coming back would probably go away anyway, but the pay differential stops people from coming back. Why would you [come back]? You are taking a substantial pay cut and earning a diminutive of what the guy next to you does. It is not a very attractive proposition for people, who are off working in good centres.

“The conditions here are not great. For example, when I worked in England, if you were looking after inpatients on the wards, your outpatient work was cancelled, whereas here in my gastroenterology job, I have to be a gastroenterologist, I have to be a general physician, I am on the wards all the time, and my clinics go ahead. The work is much harder and much more frustrating. It is just not attractive at all to people to come back. ”

Evidence

RCSI research indicates that there has been a three-fold rise in those intending to remain abroad permanently and only a quarter intended to return to practice in Ireland.

According to the RCSI, the most common reasons for emigration and reluctance to return are stressful working conditions, and unclear or unsatisfactory career progression.

The IHCA recently conducted a survey, which found all respondents (99 per cent) agree that lower salary terms are having an adverse impact on the delivery of patient care due to the large number of consultant posts that are unfilled or filled on a temporary basis.

The survey states over 70 per cent of the new consultants have confirmed that they will seriously consider resigning from their public hospital posts unless the salary terms are improved.

The IMO canvassed opinions from a group of 77 consultants and NCHDs currently working in other jurisdictions for its submission to the Public Service Pay Commission. In its survey, 71 per cent stated that improved pay would prove useful in recruiting them, and their peers, to posts within the Irish health service.

What next?

Both the IHCA and IMO have presented evidence to the Public Service Pay Commission about how salary issues have contributed to the consultant recruitment and retention crisis. The IHCA has already initiated new-entrant consultant pay discrimination cases on behalf of over 200 members of the Association. The cases were initiated after the High Court settlement and the legal letters have been addressed to the relevant Ministers and the HSE, according to the IHCA. The IMO also plans to hold more meetings with new-entrant consultants across the country and has not ruled out legal action.

“With regards to the ‘Fight for Fairness’ campaign, the IMO has commissioned a legal opinion and will discuss that with members upon receipt,” according to a spokesperson.

Consultant in Old Age Psychiatry, Dublin, North City, Dr Matthew Sadlier, also attended the IMO meeting in Santry.

Dr Sadlier says the cut could be seen to represent gender discrimination, given that the number of female medical graduates now outnumber males. Also, he says it is unlikely the health service has saved any money from the cut, as locum consultants, who are employed to fill vacancies, receive higher salaries than those paid to new entrants. Dr Sadlier says the IMO has repeatedly requested information on what evidence the Minister for Health and the Department of Health took into consideration when the cut was decided upon in 2012.

“I think there should be a report done on what has been the morbidity and mortality of this. Has this led to increased waiting lists, and has this increased waiting list led to negative health outcomes?” Dr Sadlier states.

“What was the due diligence? Why 30 per cent? Why not 20? Why not 5? Who came up with the number? Who did the analysis? Where is the analysis report? You are seriously not going to tell me that a Minister is going to make such a big decision with no prior analysis. That would be insane.”

Improving the applications process

Pay is not the only issue affecting consultant recruitment. While it may be a dominant factor, it has been recognised for some time that the recruitment process itself is lengthy and overly bureaucratic.

With this in mind, retired surgeon Prof Frank Keane was appointed by the HSE to lead a group to examine the process and make recommendations for improvements. Such an examination was recommended in the MacCraith Review of Medical Training and Career Structures. The resulting document, Towards Successful Consultant Recruitment Appointment and Retention, was published at the end of 2016.

“What tended to happen, whoever shouted loudest for a new consultant was the person that was heard,” Prof Keane tells the Medical Independent (MI). 

“It wasn’t necessarily done taking into account, one, the needs of that speciality, and two, how that fit into the rest of the healthcare requirements in that Hospital Group, etc.

“What we have tried to do is create a better planning process. It wasn’t just a knee-jerk process whereby somebody said ‘we need another specialist in this particular area’. Most of them would be justified because as you know, many specialities are very short of consultants. But we were saying that there had to be a better process.”

According to Prof Keane, a focus of the document was to “make the journey continuous” from the time a hospital requested a consultant appointment, to when that consultant was actually put in place. The document also made recommendations about the importance of supporting structures and resources in order to retain consultants within the hospital system.

Some of the recommendations centre on the Consultant Applications Advisory Committee (CAAC). The purpose of the CAAC is to provide independent and objective advice to the HSE on consultant applications. Applications for approval of permanent, new or replacement posts are submitted to the Committee via the HSE’s National Doctors Training and Planning (NDTP) unit.

 Recently, the Committee has faced issues over requirements from the Executive that pre-approval for funding was necessary in order for posts to be forwarded for consideration. As a result of the new rules, the numbers of applications to and approvals by the Committee declined by approximately half between the first half of 2016 and the same period in 2017.

While this issue was not addressed in the report, it highlights some of the challenges facing the CAAC.

The report noted the CAAC was not required to conform to any particular time scale for the consideration of applications. This meant that there was a lack of clarity as to timelines for progress of applications/resolution of issues.

The group recommended that CAAC consider and make a decision as to approve, refer for resubmission or reject an application within eight weeks of the closing date for receipt of appropriately completed applications. According to the HSE, this recommendation has been implemented.

In early 2017, the ‘CAAC Application Form’ was entirely replaced by the ‘Proposed/Approved Consultant Appointment’ document, which is now used by the Committee to evaluate the rationale and purpose of the post. The document was changed due to Prof Keane’s group noting the absence of key clinical, administrative and professional resources required to ensure newly-appointed consultants can make the most effective contribution to service provision. The new document contains a job plan and statement of resources associated with the range of services.

Another recent initiative implemented, based on the report, is online applications. NDTP was specifically tasked with the development and implementation of an online application system for approval of consultant posts. The online solution is now encompassed in the existing DIME (Doctors Integrated Management E-System) facility and was launched at the end of May 2018.

The new Consultant Application Portal (CAP) moves the Proposed/Approved Consultant Appointment document online.

CAP will enable clinical sites via Hospital Groups/Community Healthcare Organisations to complete, verify, submit and track consultant post-approval from initiation to CAAC approval.

According to the HSE, CAP will provide: A reduction in time frames; a reduction in paper trail; a reduction in errors; and a more clear and transparent process overall.

Reform of CAAC procedures was only a part of the document. The HSE has informed MI that most of the recommendations in the report have now been implemented.

Prof Keane’s group recommended that HSE Clinical Strategy and Programmes, in collaboration with Hospital Groups and the HSE Mental Health and Acute Hospitals Divisions, should lead the development of a National and Group Framework for speciality development. However, according to the HSE, the status of this recommendation is “unclear.”

The group also remarked that induction (including on-boarding) processes were absent in many instances and that newly-appointed consultants were introduced to employment in “a limited and haphazard manner”, which it says was a key driver of poor retention rates in some locations. It recommended a new induction policy to be adopted by the HSE and HSE-funded agencies.

It also asked that HSE Human Resources develop training content to bring these policies to fruition. These incorporate the full consultant life-cycle, from recruitment, on-boarding, induction, to professional development.

However, the HSE says implementation of this recommendation was dependent on the implementation of its overall induction policy, which has not yet occurred.

The group noted the inconsistent use, and even absence, of performance management/appraisal processes relating to consultant posts, including a failure to regularly review job descriptions and associated requirements for implementation of same. As a result, it recommended that the HSE National Recruitment Service and the Public Appointment Service immediately commence a job analysis of the role of a consultant to support interview/selection processes. It called for the forthcoming HSE Performance Achievement Process to be structured to take account of the particular needs of consultants and ensure regular review/appraisal of performance and individual needs for effective service delivery. The implementation of this appraisal process has been delayed pending the resolution of the recent consultant court cases, according to the HSE.

While admitting that the process of recruiting and retaining consultants could be improved, IMO President Dr Peadar Gilligan strongly criticises the HSE’s decision not to include ‘pay’ in the group’s terms of reference.

“We spoke to Prof Keane with regards to the document and we said to him that it was frankly ludicrous that he should have been asked to write a document about the challenges in consultant recruitment and yet to have the issue of pay and terms and conditions expressly excluded from the remit of the document,” Dr Gilligan tells MI.

“Now, in fairness to Prof Keane, he did address the issue and felt that it was having a very significant impact on our ability to recruit and retain. But I think it gives one an idea of the challenges for the HSE when they are commissioning documents and deliberately leaving out the major issue that the document should be addressing. To some extent, it was a hugely frustrating document.”

IHCA Secretary General Mr Martin Varley also criticises the document for not addressing the salary issue. “We have clearly set out that the consultant recruitment process itself and the other issues outlined in the Prof Keane report are not the fundamental problems which are causing the prolonged and deepening consultant recruitment and retention crisis, but the combined effects of the decade of contract breaches and the imposition of discriminatory terms on new-entrant consultants,” says Mr Varley.

Prof Keane points out that the document does note that pay is a significant issue.

“Although we did not examine it, we did point out that was a serious issue that had to be addressed,” he says.

Speaking to MI, HSE National Director of Human Resources Ms Rosarii Mannion says Prof Keane’s report was an “excellent document”, but stresses it was only a first step.

“It is going to assist [with the recruitment and retention of consultants]. There is no quick fix to some of these issues. But at least in terms of the document, any of the areas that are set out and highlighted will improve the overall experience.”

Even though the document was only published in late 2016, Ms Mannion says it was something that should be revisited and that more ambitious targets could be put in place.

“It is the first time this was done. It has helped, it has brought more focus and clarity. But it is time to revisit that again now. At all times, we want to be pushing the boundaries and trying get more consultants into the system.”

Ms Mannion adds that the recent High Court settlement should help relations between consultants and health management to move forward on recruitment issues in the future.

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