Current State funding to train doctors to be specialists in psychiatry is at least €600,000 short of what is needed, the President of the College of Psychiatrists of Ireland has warned.

Dr Lorcan Martin, a Consultant in General Adult Psychiatry, added that overall funding and staffing levels for mental health services were unacceptably low and failed to ensure patients had access to the modern, fit for purpose mental health services nationwide they need.

 Speaking ahead of his address to NCHDs in psychiatry at the College’s conference, which takes place in Dublin today, Dr Martin noted that the total budget for national mental health services was 5.6 per cent of the overall health budget and current funding for training doctors to be specialists in psychiatry was at least €600,000 short of what is needed.

He said these figures were wholly inadequate to serve the needs of some of the most vulnerable people in society who have moderate to severe mental illness. He said that there is widespread acceptance that a minimum of 10-12 per cent of the health budget (approximately €2.4 billion) should be provided for mental health services.

 Dr Martin said that there were only circa 500 specialist (consultant) psychiatrist posts in Ireland and just three-quarters of these are filled on a permanent basis by specialists. Ideally, there should be a minimum of 835 posts filled to meet growing demand.

 “At present, we do not have nearly enough doctors in psychiatry to meet patient demand. This extremely worrying resourcing crisis is a symptom of our difficulty in both recruiting doctors to the services and retaining those already working here. If we can put a meaningful plan in place to improve working conditions for doctors in psychiatry – specialists, trainee specialists and other NCHDs – supported with a plan to address our current perilously low funding, then an adequate number of appropriately trained professionals to resource services should follow,” he said.

 He said that the lack of specialist consultant psychiatrists has a direct negative impact on the training of NCHDs and could lead to significant crises such as the revelations surrounding South Kerry CAMHS. He stressed that NCHDs have a fundamental role in providing patient care in psychiatric services.

Dr Martin said that NCHDs needed to see demonstrable change. “Our NCHDs are the future of our health system and are a significant priority. The College’s training programme has seen steady growth in applications from doctors in the last number of years. It is clear they want to stay and practise in Ireland, so the Government and HSE should be doing everything in its power to make that decision an easy one by providing a well-staffed, well-funded, and appropriate working environment. That is what our patients deserve.

 “The Government must urgently implement the national plan to ensure services have adequate numbers of consultant psychiatrists for patients, but crucially too to support and supervise trainee specialists. NCHDs need to work in a positive environment promoting best practice and innovation if we are to avoid losing another generation of doctors to emigration.”

Improvements to transparency and communication with patients should be made to the HSE’s drug reimbursement process, a new report prepared by Mazars has found.

According to the Department of Health, the report found that the HSE process “is operating in line with the legislation and that it is delivering results in keeping with international norms”.

However, the report concluded that there is scope for improvements in a number of areas, including: The transparency of the process; communications with, and the availability of, information to patients; and tracking the progression of medicines through the process.

“I want to see improvements in the overall transparency of the process, and I have asked the HSE to bring forward proposals in that regard as a matter of urgency,” said the Minister for Health Stephen Donnelly. “Greater engagement with stakeholders, including patient groups, will ensure that patients are aware of the process and have sight of various steps and timelines.”

The Minister has asked the HSE to introduce an application tracker on the HSE’s website, detailing how applications progress through the process. He has also asked the HSE to introduce indicative timelines for a medicine to complete the application/approval process.  

An implementation plan is being published and an implementation working group is being established between the Department of Health and the HSE. This group will consider and progress the various recommendations contained in the Mazars Report.

HIQA has begun work on a health technology assessment (HTA) reviewing domiciliary (at home) invasive ventilation for adults with spinal cord injuries. HIQA has published the protocol that outlines the approach it will use to complete this work.

HIQA agreed to undertake this HTA following a request from the National Clinical Programme for Rehabilitation Medicine in the Health Service Executive (HSE) and the Spinal Cord System of Care Programme in the National Rehabilitation Hospital (NRH).

A spinal cord injury involves damage to the spinal cord that causes changes in its function, which can be either temporary or permanent. Damage to the spinal cord can be life-threatening or result in life-changing injuries, with the potential for long-term disability. The higher up the spinal cord the injury occurs, the more serious the symptoms will be. Given the extent of these injuries, affected individuals often have complex healthcare needs and generally require lifelong assistance with many aspects of their life.

While most individuals with high spinal cord injuries will require a ventilator initially, only a very small number will require it permanently. For these individuals, there is often a preference to receive care at home rather than staying in a hospital. HIQA’s latest HTA focuses on the small number of individuals with spinal cord injuries who require lifelong invasive ventilation and in whom discharge home is deemed appropriate by their medical team.

Dr Conor Teljeur, HIQA’s Chief Scientist, said: “In line with the ambitions of Sláintecare, there is a desire to move care out of acute hospitals and into the community, closer to people’s homes, when it is safe to do so. However, up until now, organisation of home mechanical ventilation services for ventilator-dependent individuals with spinal cord injuries in Ireland has been on a case-by-case basis, contributing to a significant administrative burden and delays in service provision.”

The HTA will assess the organisational, budget impact and resource implications, as well as the social and ethical issues arising from the provision of care to these individuals within their own home. The findings of the assessment will inform a decision by the HSE on the national delivery of care.

The HSE has confirmed that the first part of the ‘build and test’ stage for its planned integrated financial management system (IFMS) was completed on schedule at the end of 2022.

As previously reported in the Medical Independent (MI), the project has been beset by numerous delays, such as the termination of contract with the former system integrator, DXC Technology, last year.

A public procurement process was conducted for a new system integrator to build, test and implement the approved IFMS design, and IBM was engaged in July 2022.

A HSE spokesperson told MI that following the on-schedule completion of the design validation and review stage in October 2022, the IFMS project progressed to the build and test stage which runs to May 2023.

“The first milestone for build and test stage (Sprint Group 1) was completed to plan in December 2022,” according to the spokesperson.

The build and test stage also includes: The development of detailed functional specifications; management of change activities for implementation group 1 (IG1); IG1 ‘go-live’ preparation activities, including establishment in December 2022 of the IG1 steering group and local working groups; and IFMS data readiness for IG1 ‘go-live’.

Other elements of this stage are the development of a shared services operating model, including the establishment of the master data unit; the development of a procurement support model; playback demonstrations; system integration testing; and user acceptance testing.

“The project is due to progress to implementation and ‘hypercare’ stage in June 2023, with the first two of five implementation groups on track for go-live at half-year (July 2023) and at year-end (December 2023), respectively,” according to the spokesperson.

Hypercare is the period of time immediately following a system ‘go-live’ where an elevated level of support is available to ensure the adoption of a new system.

The spokesperson said the project is advancing on schedule to achieve the target of having 80 per cent of the expenditure of the health service transacted on the IFMS in 2025.

Concerns over the rate of progress with the Sláintecare reform agenda were raised at the National Health Summit in Dublin.

IHCA President Prof Robert Landers told attendees the health strategy “hasn’t yet delivered”.

He said the reform programme has not provided the promised increase in the number of hospital beds or consultant posts.

“We are all these years in the Sláintecare programme now and we are not really seeing it in the hospitals,” Prof Landers said.

He was asked during a questions and answers session whether the new consultant contract would deliver on a core aim of Sláintecare, which is removing private healthcare from public hospitals.

Prof Landers said: “It will play some role.”

“But when you look at the activity in our public hospitals at the moment, only about 4 per cent of the activity… is for private elective care,” he added.

“So, it’s going to take that out, but it is not going to deliver a huge increase in capacity that we need.”

Speaking during the same panel session, Dr Sara Burke (PhD), Director of the Centre for Health Policy and Management, Trinity College Dublin, said “the removal of private practice [from public hospitals] was never about increasing huge amounts of capacity in the system”.

“It was about providing equitable, universal access so everybody got care on the basis of need not the ability to pay. But it is just one cog in a very complicated machine and many more of those cogs need to move at the same time. So a big one that needs to move is this investment in the community… it is beginning to happen, but we need to do much more.”

Dr Burke said her overall assessment of Sláintecare was that implementation is occurring, albeit at a slow pace.

“I think if you look at all the policies and even the HSE service plans, Sláintecare is driving the policy intent. So it is there at a policy level. But I think at an implementation level, it has been slow.”

Dr Burke said that the Covid-19 pandemic contributed to implementation delays.

However, she added the pandemic also “accelerated aspects of Sláintecare”.

“We have seen a bigger investment in the health system, an investment at the level that was laid out in the original report. We have seen a significant increase in workforce despite the challenges.”

Dr Burke said that “clarity” was required on the governance of the Sláintecare programme. She said it was important to know “who is ultimately responsible for providing that reform”.

Mr Robert Watt, Secretary General at the Department of Health, was also part of the panel discussion. He said “as ever, in our system, the person who is ultimately responsible for delivering healthcare reform is Minister [for Health Stephen] Donnelly”.

According to Mr Watt, there had been some “fantastic change” taking place under Sláintecare.

“Most people in this room would also agree with that because that is their experience. But of course, we could do more and that is the challenge…. So the challenge for us is that we have this plan and we are committed to this plan.”

He also said change “can be difficult” for an organisation of the HSE’s size.

As giving evidence at court can be a daunting prospect, Dr Ian Lavelle outlines a case scenario and provides advice

As a doctor, you may be asked to give evidence in many different types of hearings throughout your career. These may include the family, criminal, civil or coroner’s court, or an employment, mental health or fitness to practise tribunal.

What happens if you are called as a witness to court?

If you are called as a witness, it may be helpful to remember that your role is to provide impartial evidence to help the court reach its decision. You will either be required as a professional witness to supply factual information obtained in your capacity as the treating doctor in a particular case, or as an expert witness to provide an independent opinion on the facts of a case that you have not been personally involved in. In either scenario, it is important to stick to the facts, and not to stray into providing opinion beyond the scope of your expertise.

You will usually be put on notice that your attendance is required and asked beforehand for dates that are convenient to you. However, if you are served with a witness summons or subpoena, you must attend at the specified time and for the set duration. If you do not comply with a witness summons, you risk being found in contempt of court – this is a criminal offence and might, in addition, result in you being reported to the Medical Council. If you receive a witness summons but believe that you have a legitimate reason for being unable to attend, you should seek advice as soon as possible from Medical Protection or your medical defence organisation.

It is worth mentioning that your duty of professional confidence is not automatically waived by being called to give evidence; therefore, you should not disclose or discuss confidential information without the patient’s express consent. If you are asked for this information, you should explain that you do not have the necessary consent to provide it and await the direction of the court. Furthermore, if you perceive any conflict of interest on your part you are obliged to make this known. However, you must disclose information when ordered by a judge in a court of law, or by a tribunal or body established by an Act of the Oireachtas.

Preparation for going to court

It is helpful to fully familiarise yourself with the case before attending court, as follows:

• Read through your report and ensure you are fully familiar with it.

• Review the medical records so that you are aware of the important facts of the case.

• Be clear who has called you to attend.

• Find out where the court is and how long it will take you to get there.

• Find out how long you will be needed for.

• Make sure the medical records and a copy of your report will be available at the court.

• Make sure you have adequate cover arrangements in place for the duration of your anticipated attendance.

On the day, you should:

• Dress professionally. In addition to being respectful, you are also likely to feel much more confident when giving your evidence.

• Get to the court in good time – there is nothing worse than rushing or arriving late.

• Take the medical records with you, if you have them, as well as a copy of your report.

• Expect to be kept waiting.

What happens?

The procedure is fairly similar for civil and criminal courts. The claimant in a civil action or the prosecution in a criminal trial will put their case first. Their witnesses will give evidence and be cross-examined; once this has happened, the other side will respond. After the evidence has been heard, both parties will make closing speeches and the judge will sum up the evidence.

In a civil case, the judge will decide, on the basis of the law and the evidence presented, whether to find in favour of the claimant or the defendant. In most cases, the judge will also decide on the level of compensation that should be paid. In a criminal case, the judge will sum up the evidence and advise the jury on the law to be applied. The jury will then deliberate on the facts and give their verdict.

Whether you are giving evidence at a civil or criminal court case, the processes start off in a similar way. When it is your turn to give evidence, you will be shown to the witness box. A court officer will ask you to swear that the evidence you are about to give is the truth.

You will firstly undergo what is known as the examination-in-chief, the purpose of which is to make your evidence clear. The lawyer for the party that called you will take you through your evidence. The judge may wish to ask you questions to further clarify your evidence at this stage.

You are then likely to be cross-examined, during which the lawyer acting for the other party will question you about your evidence. Remember: Their role is to draw attention to any contentious issues of fact or opinion.

After the cross-examination has finished, the lawyer that called you may wish to re-question you to clarify any issues that may have been raised during the cross-examination. Once this has happened, the judge may wish to question you.

Tips on giving a successful performance in the witness box:

• Remember that you are impartial – your duty is not to one side or the other. You are there to assist the court.

• Speak clearly, using short sentences – try not to over-elaborate and explain any technical terms you may have to use.

• You are giving evidence to the judge/coroner/chair, so ensure that you face them when answering a question.

• Listen carefully to each question. Make every answer open, honest, and fair.

• If you don’t know the answer or understand the question, say so.

• Don’t lose your patience with the opposing counsel. Lawyers are working on behalf of their clients and disparaging comments can be a deliberate tactic – the best witnesses are those that remain neutral and focused.

• You can appeal to the judge if you feel that a question is improper, or if you would like to expand on your answer.

• Remember to take as much time as you need for each answer. A conscientious witness will pause for as long as necessary before speaking to ensure that they are giving evidence that really is “the truth, the whole truth, and nothing but the truth”.

It is advisable to contact your medical defence organisation if you receive a request to attend a hearing.

An Irish stem cell transplant service for children would “reduce the financial, logistical and emotional burden” on families, a new Health Information and Quality Authority (HIQA) report has found.

HIQA published a Health Technology Assessment (HTA) on the repatriation of paediatric haematopoietic stem cell transplant (allogeneic haematopoietic stem cell transplant (HSCT)) services to Ireland.

The HTA was undertaken following a request from the HSE.

According to HIQA, the HTA examined the choice of treatment location for children with certain rare, inherited conditions who require stem cell transplants. HSCT treatment for these patients has typically been provided in the UK and funded through the HSE’s Treatment Abroad Scheme. These conditions include inborn errors of metabolism, inborn errors of immunity and haemoglobinopathies, conditions which disproportionately affect ethnic minorities within Ireland.

The HSE has an accredited HSCT service in Children’s Health Ireland (CHI) at Crumlin. Children with other conditions, such as leukaemia, receive their transplant at this location.

HIQA found that repatriating HSCT services for children who currently receive the treatment in the UK would potentially double the number of paediatric allogeneic (donor derived) HSCT procedures that would be carried out in Ireland every year.

HIQA also found that while demand for HSCT will vary from year to year, on average, the HSE would have sufficient bed capacity to accommodate the patients currently treated in the UK. HIQA’s estimates take account of the greater number of dedicated transplant beds that will be available when services move to the new National Children’s Hospital.

However, the ability to repatriate the service would rely on the recruitment of additional staff, such as skilled nursing staff and support staff, across a range of disciplines. HIQA noted that phased approach to implementation may be required to support the build-up of sustainable capacity within the service.

 “When a child needs to undergo a stem cell transplant this experience is incredibly stressful for families,” said HIQA’s Deputy CEO and Director of Health Technology Assessment Dr Máirín Ryan.

“The need to travel abroad increases the stress further, with children and their parents having to remain abroad for periods of between two and six months. This means that families are separated from one another for long periods. Our assessment found that repatriation of stem cell transplants to Ireland would reduce the financial, logistical and emotional burden that these families face.”

The IHCA has warned that the ongoing shortage of consultants across Cork hospitals and unaddressed bed capacity deficits is restricting patients from accessing timely, high-quality medical and surgical care and is contributing significantly to growing waiting list.

The six hospitals in the Cork region saw 2,300 additional people added to their waiting lists for outpatient appointments and procedures in 2022 – a increase of almost 3.2 per cent.

This compares with a modest reduction of five per cent (-7,800) in the number of people on the three main waiting lists under the Government’s Waiting List Action Plan across the wider South/South West Hospital Group (SSWHG), and a four per cent (-28,900) fall nationwide.

This means the plan missed its key targets in the region, according to the Association.

The IHCA analysis shows that Cork hospitals saw their waiting lists increase rather than decrease last year.

The six Cork hospitals are: Cork University Hospital; Cork University Maternity Hospital; Mercy University Hospital; South Infirmary Victoria University Hospital; Bantry General Hospital; and Mallow General Hospital.

Collectively these hospitals were 17,400 outpatient appointments and procedures away from meeting the 18 per cent reduction target for the end of 2022.

Currently more than 84,400 people are awaiting an outpatient appointment or inpatient/day case procedure across county Cork.

Consultants have raised their concerns that the combination of the unprecedented spike in hospital overcrowding, the longstanding deficits in hospital capacity and the record vacant consultant posts in the region could see the number of people on hospital waiting lists in the region reach new record highs in the months ahead.

Commenting on the figures for the Cork hospitals, IHCA President Prof Robert Landers said:

“The severe shortage of hospital consultants in our public health service in Cork and the southern region is the main contributor to the unacceptable delays in providing care to patients. We have a chronic recruitment and retention crisis with one in five permanent hospital Consultant posts not filled as need across Cork hospitals –  that’s 73 consultant posts either vacant or filled on a temporary or agency basis. The figure nationally is over 900 unfilled consultant posts.

“This has led to a situation where we have more than 84,400 people awaiting an outpatient appointment or inpatient/day case procedure in hospitals across Cork and 140,000 in total across the South/ South-West. This is 40,000 more than the number waiting for care across the region eight years ago.

“Cork hospitals have seen the average number of available inpatient and day case beds increase by just 19 beds over the past three years to 1,478 beds. This equates to less than three per cent of the total number of additional hospital beds opened nationally since the start of the pandemic.  This is a shocking indictment of the lack of urgency on the part of the health service management to address the clear bed capacity deficits in the region, which would relieve some of the chronic hospital overcrowding recently witnessed.”

“However, reducing the number of people on waiting list to be treated or seen by a consultant in a Cork hospital will only be possible by filling the one in five permanent hospital posts that are currently unfilled and appointing significant additional consultants.”

The IMO has warned that the ongoing capacity crisis in the health system is directly leading to “sustained and critical risks” on a daily basis to both patients and healthcare staff.

Representatives from the IMO addressed the joint Oireachtas committee on health on the welfare and safety of workers and patients in the public health service today (Wednesday 8 February).

IMO President Dr Clive Kilgallen said that patient and staff welfare issues are endemic in a system that is continually operating beyond safe capacity limits.

“While each winter record levels of overcrowding make headline news, our hospitals are operating beyond safe capacity limits all year round, leading to sustained and critical risks,” he said.

“This is neither a winter crisis nor one caused by Covid or other respiratory illnesses – this is a crisis of capacity with insufficient investment in workforce planning, beds and all other physical infrastructure.”

The IMO outlined the risks faced by patients in a health system that is overcrowded on a daily basis, including:

• Delays in admission from the emergency department (ED) are associated with increased mortality (within 30 days) and poorer outcomes for patients; it is estimated that up to 400 people could die every year as a result of ED overcrowding; 
• Studies have shown that ED overcrowding is associated with delays to receiving pain relief, medication errors and greater hospital lengths of stay;
• Hospital overcrowding contributes to the spread of healthcare associated infections and the risk of adverse events due to rationing of resources and elevated stress levels;
• Long waiting lists add delays in diagnosis and treatment inevitably mean that patients are treated at a more advanced and complex stage of illness while overcrowding can lead to the further cancellation of non-urgent care.

The IMO added that staff and patients are placed at additional unnecessary risk because of our capacity crisis. This has led to widespread burnout, with findings from a recent survey conducted by the IMO including:

• 94 per cent of doctors reported having experienced some form of depression, anxiety, exhaustion, stress, emotional stress or other mental health condition relating to or made worse by work;
• 81 per cent of doctors are at risk of burnout.

The IMO emphasised that short-term solutions to address this crisis are neither acceptable nor realistic. It recommends the following course of action:

• Urgent investment in bed capacity and steps taken to ensure that our hospitals operate at the recommended safe occupancy levels of 85 per cent;
• Determine and resource appropriate and safe staffing levels based on population needs;
• Urgently address the underlying issues of chronic staff shortages and workload pressures that impact the wellbeing of doctors;
• Create a better working environment ­- A recent paper from the OECD found that improving worker well-being has intrinsic value, but it also lowers the costs of occupational harm (estimated at up to two per cent of health spending) and contributes to minimising adverse outcomes for patients (estimated at up to 12 per cent of health spending worldwide);
• Ensure clear policies and procedures are in place so all healthcare professionals feel able to take breaks and to take time off when ill;
• Increase efficiency and patient safety through ongoing investment and development of e-health including investment in electronic health records in acute hospital and community settings and the roll-out of e-health initiatives;
• Ensure risk assessments consider both patient and staff welfare;
• Without any further delay, all healthcare workers should have access to appropriately resourced, fully consultant led occupational health services including mental health supports;
• Address stigma and encourage the use of support services.