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In recent years there have been efforts at improving processes around consultant recruitment. As talks commence on a new contract, Paul Mulholland asks whether this work has eased any of the problems around filling vacant posts.
Much of the focus concerning the recruitment of consultants into the health service has focused on remuneration. Medical representative groups have repeatedly highlighted how the salary cut imposed on so-called ‘new-entrant’ consultants in 2012 has been responsible for the high number of vacant posts. However, the need to improve the manner in which consultants are hired into the health service has also been recognised for some time.
One of the recommendations made in the MacCraith Review of Medical Training and Career Structures (2013-2014) was for the HSE to review processes around consultant recruitment. Retired surgeon Prof Frank Keane was appointed to lead a review group and the resulting document, Towards successful consultant recruitment, appointment, and retention (Keane report), was published in December 2016.
The aim of the document was to improve the continuity between the time a hospital requested a consultant appointment to when that consultant was put in place. It also made recommendations about the importance of supporting structures and resources in order to retain consultants within the hospital system. A key recommendation of the MacCraith review was the need to chart the relationship between work objectives, flexible working, available resources, and supports. These and other matters were addressed in the Keane report. Some of the central recommendations concerned the operation of the consultant applications advisory committee (CAAC) and the move towards facilitating online applications (see panel below).
The group “noted that there is scope for significant improvement in governance and administration prior to and during the application and approval process for consultant posts and subsequently in the recruitment and appointment process”
National Service Plan 2021
Work on implementing the Keane report’s recommendations has been ongoing. The HSE has also continued to monitor how consultant applications are being processed. In order to meet the resourcing commitments outlined in the HSE National Service Plan 2021, a recruitment and resourcing governance steering group was established by the
HSE. In line with the work of this group, another small working group has been set up specifically to examine processes around recruitment of medical consultants given the continuing difficulties filling posts.
“This builds on work to implement the [Keane report] recommendations in previous years,” a spokesperson for the Executive told the Medical Independent (MI).
The objectives of the working group were set as follows: To identify short- and longerterm areas for improvement/streamlining within the permanent consultant recruitment process; to act on areas identified in order to achieve timely outcomes; to develop “robust stakeholder communication strategies”; to work in a “collaborative manner” and be open to improvements within the sector each member represents; and to provide progress reports to the National Director of Human Resources and steering groups and to escalate any concerns/risks where appropriate.
“It is acknowledged that significant work has already taken place in this area and would form part of the deliberations, considerations and decisions of the working group,” according to the spokesperson.
“This included Towards successful consultant recruitment, appointment, and retention, together with the lessons learned from the recent local consultant recruitment pilot project.”
This pilot project involved Hospital Groups directly appointing consultants rather than going through the Public Appointments Service (PAS) (see bottom panel).
The working group has identified the need for a consistent approach to exposure prone procedures (EPPs) in pre-employment health assessments. Collectively, the Chief Medical Officer’s office within the civil service and the HSE occupational health office have reviewed and agreed a standardised approach for all employers to follow, clearly outlining the standard EPP requirements.
The agreed list has been circulated to the PAS and the medical manpower managers group for immediate implementation.
In order to implement a recommendation contained in the Keane report, in 2018 the HSE commissioned a medical consultant job analysis exercise that was conducted by the PAS. The resulting published framework, A Competency
Framework for the Appointment of Medical Consultants to Tenured HSE Posts (ROI) – October 2018, was examined by
the current working group and put forward for formal approval and endorsement by the HSE for use. These competencies have been incorporated into the updated job specification template document. The competencies will be reviewed in 18-24 months to ensure they remain aligned with international best practice, according to the Executive.
Revised screening processes have also been implemented to reduce duplication and time to hire, all of which were subject to risk assessment. These include: International police clearance; Garda clearance; validation of qualifications and further training; pre-interview checks; and post-interview checks. In terms of validation of qualifications and further training, once the candidate has met the HSE eligibility requirements and registered with the Medical Council on the specialist division of the register, the Executive will not require their original degree or CSCST certificates. The HSE’s national recruitment service (NRS) will validate that the applicant is on the Medical Council’s register. Reference to the qualifications will be included in the statutory declaration form, providing further validation assurance.
Marketing and extending global reach
According to the HSE spokesperson: “It is recognised that together with the process improvements that the HSE requires a single platform for consultant recruitment to enhance the overall candidate experience and improve the visibility and accessibility to opportunities in Ireland.
To this end, a microsite is being developed within the PAS to provide all the relevant information in “an easy, accessible form” for all potential applicants. The PAS and HSE are working to provide “consolidated campaigns” to maximise the global reach and the number of qualified candidates. An example of this is the recruitment strategy for new consultant posts in public health medicine, according to the HSE spokesperson. On 24 September, the HSE launched a recruitment campaign for six Area Directors of Public Health as part of an agreement to introduce a consultant-delivered service delivery model for the area. This campaign follows the recent launch of the National Director of Public Health campaign.
At the time of the publication of the Keane report in December 2016, there were 2,993 approved permanent consultant posts in Ireland. In December 2020, there were 3,453 such posts, according to the latest CAAC annual report. However, the Medical Workforce Report 2020-2021, produced by national doctors training and planning, highlighted the continuing difficulties in the area
“The overall number of NCHDs continues to grow faster than the rate of consultant posts and moves the HSE further away from the policy of a consultant-delivered service,” the report states. While there has been an increase in numbers, one third of all consultants working in these hospitals are 55 years or over. Also, model 3 hospitals are more likely to employ consultants not on the specialist register as well as consultants in non-permanent posts that have not been approved by the CAAC.
“An international comparison of consultant and NCHD numbers across comparable healthcare systems indicates that while Ireland has the lowest ratio of consultants per 100,000 of the population, it has the highest ratio of NCHDs,” according to the report.
When it comes to consultant recruitment, the matter of remuneration is difficult to escape. The Keane report itself pointed out that “simply correcting and providing rigour to the recruitment and appointment process was not of itself enough to address the present consultant recruitment crisis”, and that other factors, such as pay, had to be addressed. According to the IHCA, the Keane report was never going to be effective because it did not address this key issue. “At its core, it failed to address the then bad, and now worse, consultant recruitment and retention crisis as it avoided the analysis and recommendations on the root cause – the implementation of the consultant pay disparity in 2012,” a spokesperson for the Association told MI.
“While it referred to the difference between the new and older salary scale at the final point of the scale as a problem,
it failed to acknowledge the extent of the 2012 pay disparity was far greater – and which has now continued to grow over the last five years.
“Today, one-in-five consultant posts are not filled as needed due to the inability of the system to attract and retain our
highly trained consultant talent. The sad reality is there could be more Irish-trained consultants in the ICUs and emergency departments of Australia and New Zealand than there will be in our own acute public hospitals, and until we can create a health system that medical specialists want to work in, this reality is likely to continue.
Consultant contract negotiations between medical representative groups and health management, which began on 2
September under independent Chair Ms Marguerite Bolger SC, will focus on resolving issues concerning salary.
The IMO is of a similar view to the IHCA regarding the Keane report. IMO Director of Industrial Relations Mr Anthony Owens told MI the report noted that “the continuing difference between new and older salary scales” was a “source of concern” for candidates for consultant posts. Mr Owens highlighted that the report stated that “a key concern for many potential candidates for consultant posts in recent years has been income”, particularly in comparison to colleagues already in post.
“Serious concerns relating to salary differentials remain, and until these are definitively resolved, it will be difficult to tell for certain if the recommendations of the report have been a success, or successfully implemented, or if there remain an insufficient number of applicants to test the robustness of the process,” according to Mr Owens.
Reforming the CAAC
Modernising the consultant applications advisory committee (CAAC) application process by moving online was a key recommendation from Towards successful consultant recruitment, appointment, and retention (Keane report). After months of testing, the consultant application portal (CAP) module of the doctors integrated management e-system (DIME) went live in February 2018, and was rolled out nationally in June of that year. The portal facilitates clinical sites/Hospital Groups/Community Healthcare Organisations to complete, verify, submit, and track the consultant application form from initiation to approval online. It was also designed to bring about a reduction in timeframes.
“The introduction of this module has helped to minimise errors and improve traceability of forms as well as providing a centralised paperless system for all users to access,” according to the CAAC annual report 2020.
“A primary focus for the consultant division within NDTP [national doctors training and planning] for 2021 will be looking at enhancing this module to include new features. The expectation is that a lot of the current manual aspects will be automated and that CAAC members will be able to access relevant documents via CAP.”
However, the cyberattack on the HSE earlier this year has delayed this plan. Speaking to the Medical Independent, Chair of the CAAC Prof Áine Carroll said it was not possible to use the CAP following the cyberattack and applications had to be processed in the traditional manner.
“What happened then, people pivoted once again and went back to the old paper applications,” Prof Carroll said. “The different organisations within hospitals and community for the psychiatric posts, they responded very, very quickly. They were able to adapt to that, which meant that we were able to process, not through the DIME system, but through an alternative system, so we could once again go about our business.”
However, in general, Prof Carroll said the CAP has improved the manner in which consultant applications are handled.
“It always takes time for people to get used to any type of a new system, but it has been very smooth,” she stated.
“The time it takes to process these applications has certainly sped up. The number of posts that is considered at our meetings is very high. So any delays in the whole process aren’t at CAAC.”
The Government framework for Covid-19 saw CAAC meetings start to be held virtually from April 2020. There was no disruption to the planned schedule of meetings. There were 10 meetings (eight online) held during 2020, with an average of 30 applications considered at each meeting (300 in total). This is an average decrease of four from 2019.
A total of two of the applications submitted were subsequently withdrawn by the clinical sites and not considered by CAAC due to additional information being required. “We pivoted to the virtual environment very well and were able to go about the business of CAAC,” according to Prof Carroll.
“Actually I’m sure when we reflect, when the whole issue with the cyberattack has finally left us, we are going to ask ‘do we go back to face-to-face, or do we look at a hybrid’. We will take the view of colleagues about how they would like things to continue into the future. Overall, it was a very positive experience for everybody. It presents its challenges, especially if you are on a clinical site. But it has made participation, especially for those who would have travelled long distances, easier.”
In terms of other reforms involving the committee, the processes for completing the CAAC application form and national recruitment service (NRS) medical consultant job specification have been revised. The development process for both has been sequenced and streamlined to maximise efficiency and reduce duplication of effort.
A video explaining the revised process, a guidance document ‘How to complete CAAC application form and NRS job spec template’, and a series of training videos will soon be available on the HSE recruitment and selection toolkit site on HSeLanD (the HSE’s online learning and development portal) to support those engaged in working on the CAAC application form/medical consultant job specifications.
In addition, a revised NRS medical consultant job specification template is now available in the medical and dental section of the HSE human resources job specification repository, along with a sample completed job specification. The template should be used by those involved in generating medical consultant job specifications, and in conjunction with the other supports, provide guidance on how to write the job specification effectively and in line with good practice.
The benefits of direct recruitment
The HSE’s national recruitment service (NRS) uses the Public Appointments Service (PAS) as the centralised provider of recruitment, assessment and selection services relating to permanent consultant posts. According to the Towards successful consultant recruitment, appointment, and retention report, the PAS “has indicated that it has no objection, should the HSE wish to restructure the process, to the NRS taking full responsibility for all aspects of consultant recruitment”.
Permanent and non-permanent consultant staff within services funded by the HSE under Section 38 of the Health Act 2004 Section 38 Agencies are recruited directly by the relevant service. Speaking to the Medical Independent (MI) in 2019, HSE National Director of Acute Operations Mr Liam Woods pointed out that as voluntary hospitals do not go through the PAS “they tend to recruit more quickly”
That year, the HSE piloted a new process in which consultants were recruited directly by Hospital Groups or Community Healthcare Organisations (CHOs). University of Limerick Hospitals Group (ULHG) and RCSI Hospitals Group were the two Hospital Groups selected for the pilot. According to a national doctors training and planning division report on the employment of consultants not registered on the special division (May 2019): “The justification for evaluating improvements to the current average timeline of greater than 22 months for recruitment of consultants was to allow CHOs and hospital to manage the various service priorities by progressing consultant recruitment in a timely manner.”
“During the later series of site visits by the project team, there was a growing awareness that two hospital groups and one CHO had been designated to pilot consultant recruitment at local level without the involvement of PAS. Other sites would have liked to be chosen as the pilot location. Some CHOs expressed the view that they would be unable to pursue consultant recruitment at local level because of deficits in, or absence of, a medical manpower function.”
A spokesperson for ULHG said recruiting consultants to the Hospital previously took up to two years.
Of the 11 posts advertised initially in April 2019 as part of the pilot project, seven were filled.
“The timeframe between interview and appointment of the consultant varied from three to nine months,” the spokesperson told MI.
“The length of that timeframe is influenced by a number of factors. For example, the consultant may be waiting for specialist registration or in the process of completing a Fellowship, or working abroad. The clearance process is quite lengthy, and in line with the processes carried out by PAS, and with the Commission for Public Service Appointments code of practice for appointment of posts to the civil and public service.”
Since June 2019, ULHG has made 22 appointments to permanent consultant posts from its own recruitment and interview processes, and it will have another two consultants commencing with the Group before the end of the year.
“Having an ‘in-house’ process for the recruitment of permanent consultants, while also mirroring the PAS standards, has huge advantages for the Group. We are in control of the process from start to finish and may liaise with our own consultants when advertising any posts,” according to the spokesperson.
“One major advantage is that these are such specialist posts and our own consultants are aware of the field of candidates available nationally and internationally for these posts, and when they are graduating from their specialist training schemes, etc.”
Clinical Director of RCSI Hospitals Prof Paddy Broe also said the pilot project has been successful in shortening the recruitment process in the Group. “It’s a much more speedy process when done locally than the Public Appointments Service,” Prof Broe told MI.
“Certainly on ‘application to interview’, that timeframe is hugely shortened. And ‘shortlisting to interview’, we can do that much more efficiently. The time from interview to actually taking up the post depends on if the person is on Fellowship abroad; they need to complete their Fellowship before they come back. But for people who are immediately available, we can have them boarded and starting within three months.”
For the pilot, RCSI Hospitals primarily utilised the recruitment process already in place at Beaumont Hospital, Dublin. Beaumont is one of the two voluntary hospitals in the Group. The other voluntary hospital, the Rotunda Hospital, was used in the direct recruitment of consultant obstetricians. Prof Broe described the process as “much more personal” than the traditional recruitment method, which helped drive greater efficiencies.
At its board of directors meeting on 10 March, the minutes of which were seen by MI through FoI, Saolta University Health Care Group expressed an interest in the outcomes of the pilot project. The discussion referred to difficulties in recruiting consultants to Letterkenny University Hospital “due to location”. However, Prof Broe said that direct recruitment was not the solution to the issue of recruitment to smaller hospitals. He suggested that in such cases suitable candidates needed to be specifically identified. “We still have problems. Our processes are much slicker with doing it autonomously. But we still would have issues around recruitment because of a lack of interest of people taking particular jobs.”
However, Prof Broe added that other Groups, such as Saolta, could benefit from direct recruitment. “I think it is the right way to go. Saolta don’t have a voluntary hospital. But if they were empowered, the human resources departments in the statutory hospitals could do what we are doing, no problem. Recruitment is a difficult enough process without waiting for months and years to get people on board.”
According to the HSE National Service Plan 2020, the intention was to scale up the local recruitment process based upon the outcomes of the pilot sites. However, MI was awaiting a response at press time concerning the HSE’s plans for building on the pilot project.