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The difficulty in recruiting consultants into the public health service has been evident for some time.
Figures show that 20 (13 per cent) of the 149 consultant posts advertised in 2015 received no applications, while a further 28 (19 per cent) had only one applicant.
Many reasons have been posited for this difficulty: Insufficient salaries; poor working conditions; and bureaucratic delays. The previous Government established a working group in 2013 to examine the whole area of medical manpower planning. The subsequent final report of the Strategic Review of Medical Training and Career Structure Working Group made a number of recommendations to improve how the career path of medical graduates and NCHDs could be improved.
One of the recommendations was that the issue of consultant recruitment be addressed. In the wake of the report, another committee chaired by Prof Frank Keane was established to examine the issue and recommend solutions.
The remit of the committee, which was established in late 2015/early 2016, involved looking at the operational and administrative barriers to consultant recruitment, rather than remuneration. The reason for not focusing on the financial aspect of the problem was that the Labour Relations Commission proposals of 7 January 2015, which related to a new career and pay structure for consultants, were already being implemented. HSE Director General Mr Tony O’Brien felt that improvements made to the process through which consultants were recruited could help fill the high number of vacancies that have emerged in recent years.
Prof Frank Keane
Prof Keane told the Medical Independent (MI) that he accepted the role as Chairman on the condition that recommendations from the committee’s work would be implemented. He said the problem of recruiting consultants is “multi-factorial”.
“The health service itself is not working particularly well,” said Prof Keane.
“It is not an easy environment to work in; it is getting a lot of bad press and that is deterring people from coming back and working in Ireland — graduates particularly who go abroad. There is a multi-pronged effort to try and resolve the problem, and trying to actually look and see what the problems are first of all, and then try to put in place measures to actually resolve these issues.”
The final report of the committee, Towards Successful Consultant Recruitment, Appointment and Retention, was recently published. The document lists the reasons why consultant recruitment has been hampered and also makes proposals to solve the problem. The committee acknowledged that salary was an important consideration for consultants, even if the subject was beyond its remit. It noted that although the 2015 salary rates represented a partial restoration of pre-October 2012 levels, consultants appointed under these rates take longer to progress to the final point on the scale, which is below that paid to a consultant appointed prior to October 2012.
One of the main findings of the committee was that there are too many steps in the current processes for application, approval and recruitment of consultant posts, particularly in relation to HSE posts. Documentation associated with current processes is bureaucratic and not fit-for-purpose, according to the document.
The committee also found the health service had not linked the creation of additional consultant posts to the availability of potential candidates. It found many candidates were doctors in HSE-funded training or who had recently completed HSE-funded training. Also, potential candidates for consultant posts could not easily access information on forthcoming opportunities, while employers took lengthy periods to progress applications for approval of replacement posts.
Central guidance dealt only with limited aspects of the application, approval and recruitment process and was out-of-date. Even when posts were approved, there were further delays before posts were advertised, and such delays required appointment of non-permanent consultants to meet service needs pending the permanent appointment.
The report stated that advertisements lacked detailed information on the role, which was commonly provided in other jurisdictions. Once posts were offered, candidates often delayed taking up appointment. On taking up their posts, new consultants frequently experienced inconsistent induction processes and were often faced with limited resources.
In summary terms, poor governance and administration processes prior to and during the application and approval process, and subsequently in the recruitment and appointment process, made it difficult to rapidly and efficiently create and fill consultant posts. The committee identified the specific areas in the process where improvements could be made.
In all, the committee makes 38 recommendations, along with set timelines for implementation. To address the complications in the application procedures, the committee recommended that all documentation associated with approval of a consultant appointment is included in a single consultant appointment document pack. The pack should include proposed nominees for shortlisting and interview board membership and contact details for the relevant Clinical Director/Executive Clinical Director. The pack should be used throughout the process of post creation, approval and recruitment and be made available to candidates as background information.
The documentation itself needs to be shortened and simplified.
The committee recommended that HSE National Doctors Training and Planning (NDTP) and the HSE National Recruitment Service progress the development of an online application system for posts accessible to employers and regulatory and recruitment functions. This system should eliminate the multiple forms in use currently, according to the final report.
The committee noted that clarity regarding funding was essential if posts were to progress without delay from application to appointment. In some cases, posts had been placed on hold following approval, as concerns had emerged regarding funding. It recommends that both the ‘proposed/approved consultant appointment’ document and related pack explicitly provide for confirmation of funding in line with the Hospital Group/Community Healthcare Organisation (CHO)-funded work plan and is certified by the Group CEO/CHO Chief Officer and National Directors in acute hospitals and mental health divisions.
Another recommendation is that the relevant consultant grouping is consulted prior to submission of an application and that this consultation is recorded on the ‘proposed/approved consultant appointment’ document.
The report noted that the Consultant Applications Advisory Committee (CAAC), which provides independent advice to the HSE on consultant applications, is not required to work within a defined timescale. The report therefore 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. It should also terminate consideration of applications where no response has been received from the applicant facilities to queries after three months.
Similarly, it recommended that HSE HR make a decision regarding posts recommended for approval by CAAC and authorises the issue of a letter of approval within one week of receipt from the NDTP.
The committee also recommended that the HSE/Public Appointment Service restructure the clearance process to the greatest extent possible within legal and regulatory constraints to ensure that clearance information sought from candidates is provided in a timely fashion.
Instead of applications being first sent to the CAAC and, once approved, for further documents to be submitted to the National Recruitment Service, it recommended that all documents should form part of the single pack, to be submitted at the beginning of the application process.
The committee noted delays in the issue and/or finalisation of contract documentation for successful candidates.
In some cases, delays of up to five months have occurred. It recommended that consultant recruitment is prioritised at Hospital Group/CHO level and that hospitals/agencies are required to complete contract documentation within two weeks of notification of the successful candidate.
“This document not only looks at the recruitment process, but it looks at how the information can be better put out to the candidate, how it can be a little bit more welcoming, making it more transparent, both for the employer and for the candidates, so they know what the processes are and what they should be,” according to Prof Keane.
“And that whole process continues throughout their appointment, initially when they are inducted into the job so that they get a proper induction process when they arrive at the job, so they know what they are doing and it is absolutely clear and specified, etc.”
The committee recommended that the implementation of the report should be led by HSE HR, which should nominate a member of staff to head the process. It also called for implementation of these actions to be integrated with HSE performance achievement and HSE National Performance Oversight Group (NPOG) processes.
“It is pretty clear on what the outcomes should be,” Prof Keane said. “It is a package of documents. There is also a document on induction, a document on what employers should do in terms of putting together a job plan, and what are the things they should include in that job plan. In other words, they should include what support services that consultant is going to get, which is of essential importance.”
Prof Keane said many of the proposals have already been implemented.
“Implementation ultimately is going to depend on the HSE itself, but also the individual institutions,” he said. “Whereas before, the process was vague and bad practice was common, now it is much more explicit, which will put us in a better position to recruit consultants.”