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What’s another year?

Medical Council Chief Executive Mr Bill Prasifka has described this past year as “a very productive period” for the Council, and its recently-published annual report for 2016 shows that the medical register is at its highest ever number, with over 21,700 doctors registered to practise in Ireland.

With all the talk of a medical recruitment and retention crisis, it may seem strange that the medical register has reached a record peak. But speaking to the Medical Independent (MI) last week, Mr Prasifka said this is as a result of a number of different trends.

“There is a lot of negativity about the profession and there are a lot of doctors who are leaving [Ireland],” he said.

“But then there are a lot of doctors who are coming in. The one thing that really strikes me is that there is a great demand for doctors in Ireland; we know anecdotally and in reality that there are a lot of posts that are unfilled, there are gaps in particular in the GP services around the country.

“So there is a great need for doctors. But also indicated by the figures is the continuing increase in the number of doctors coming in from outside the EU. It is a combination of a great deal of demand and people coming in to the country.”

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Medical Council CEO Mr Bill Prasifka

Specialists

Concerns over consultant posts in public hospitals being filled by non-specialist doctors was recently raised by the IHCA. Speaking last month, IHCA Secretary General Mr Martin Varley said the consultant recruitment crisis has created this issue.

“As a result, there is a growing risk that temporary appointees, who do not have the required specialist training and qualifications, will become entitled to permanent consultant posts once they become eligible for ‘contracts of indefinite duration’ after four years in-post,” said Mr Varley.

According to the Council’s 2016 annual report, 42 per cent of doctors on the medical register are on the general register, while 40 per cent are on the specialist register.

Mr Prasifka said the Council has noted this trend, however it is a challenge to be faced primarily by employers within the health service.

“We have to operate under the Medical Practitioners Act and the issue here is the appointment of consultants who are not on the specialist register. The simple fact is that under the Act, ‘consultant’ is not a defined term,” Mr Prasifka told MI.

“A ‘consultant’ is effectively an internal HR term used by the employer. The only legal requirement in Ireland is that, number one, if you practise medicine you must be on the register, and number two, if you hold yourself out as a specialist, you must be on the specialist register.

“Let’s put it this way: We are concerned with consultants being hired who are not on the specialist register. Such a practice is in fact contrary to the HSE’s own guidelines. But there is a very limited role for the Medical Council here because the term ‘consultant’ is not a defined term.”

Complaints

Issues around complaints against doctors and public Fitness to Practise (FTP) inquiries are often raised with the Council by medical unions. In 2016, 411 complaints about doctors were received by the Council, an increase of 11 per cent on the previous year. Much of the national media coverage of the annual report highlighted the increase in complaints against overseas doctors, however the Council noted that the typical doctor facing a complaint is Irish-trained, middle-aged and male.

Another interesting trend highlighted in the report was the increase in FTP inquiries held in private last year — 25, compared to just 12 in 2015.

In terms of public inquires, there was an increase from 18 in 2015 to 20 last year. 

However, Mr Prasifka insisted that this increase in private hearings had not resulted from a conscious decision taken by the Council.

“… of the complaints made, only 10-to-15 per cent go to inquiry. That has always been the case. Of those that go to inquiry, an application can be made by either party, by the doctor or the complainant, for all or part of the hearing to be heard in private,” he explained.

“It is up to the panel who chairs the case to make a decision. Yes, there has been a growing number of cases that have been held in private. Most of the applications that are made to be held in private are made by witnesses, obviously, who want their privacy protected.

“Clearly, the Medical Council is sensitive to the needs of witnesses and complainants. But then also, there are applications made by doctors and those are given very careful consideration. But I mean, all these applications are considered on a case by case basis.”

Public hearings

While the number of FTP inquires heard in public last year did not increase as much as private ones, the impact of such a hearing on doctors’ personal and professional lives is a constant issue of concern for the medical representative bodies. At the IMO AGM in April this year, the union passed a motion calling for major changes in the FTP process. The motion passed called for the introduction of a “tiered complaints process so that complaints [against doctors] are categorised according to the severity of the complaint”.

 The motion also said the identity of a doctor should be protected during the investigation of any complaint “pending any adverse finding upon which the identity and sanction will be made public”.

The head of the Medical Council told MI that he understands the concerns, but added that doctors need to seek changes in the Act if they want to see a new reality with FTP Inquires.

“We are quite aware of this view amongst the profession and we are very sensitive to it,” said Mr Prasifka.

“Again, we are governed by the Act and the Act is quite prescriptive in terms of what the Medical Council must do when a complaint comes in. It is very prescriptive; it is almost like the complaint goes on a kind of ‘conveyor belt’. In the very early stage of the process, it has to go to the Preliminarily Proceedings Committee and there is only a limited number of things they can do with it.

“For example, they cannot resolve the complaint by accepting an undertaking and element of rectification by the practitioner; the Act does not allow them to do that. Then they have to go to an FTP Committee for further investigation, [then] a hearing takes place.”

But the Council has something in common with the IMO and other medical representative bodies — it would like to see changes to the current complaints system.

Adversarial

“What we would like to see, and what we have advocated with the Department of Health, is to give us a lot more flexibility in terms of dealing with complaints,” Mr Prasifka tells MI.

“There should be an attempt at informal and non-adversarial resolution [and] mediation. Sometimes, what the complainant really wants is information. So we should be able to do that, to be able to handle more complaints informally.

“Now, the other thing that we hear from some members of the profession is that they don’t like the fact that many inquires are held in public. Well, again, the Act provides that hearings are held in public, but then it also provides that an application can be made for them to be held in private.

“The Act says quite clearly that the default position is that all inquiries are held in public. So again, it is simply a matter of the Act, and if the profession wants that changed, there needs to be a change in the Act.”

Mr Prasifka also noted that the cost of these inquires is becoming more expensive for the Council to bear.

“The cost to us is primarily in terms of the legal fees. They have been increasing,” he said.  “Even though with inquiries the number only increased by about 15 per cent [last year], the number of inquiry days we had in 2016 was almost double what they were in the previous year.”

“Why is that? Well, it just seems to me that we live in a world where cases seem to be more and more complicated, particularly when you have cases that involve difficult decisions or require expert testimony. Cases have become more complicated and take more time and therefore are more costly.”

Bullying

The Council has also published its new Your Training Counts survey, which found that 36 per cent of trainees had experienced bullying or harassment in their training posts.

“Those [stats] did not show any improvement,” Mr Prasifka acknowledged.

“It is a significant problem. The one thing that gives us both concern and an element of understanding is that this problem is not unique to Ireland. Internationally, this is a problem. There are a lot of international information surveys done. We are not alone. Since we have been doing the Your Training Counts [survey], we have engaged very much with the postgraduate training bodies.

“When we are doing accreditation of medical schools and site inspections, we are looking at issues of bullying and what structures the institutions have in place to detect it, to deal with it, manage it and rectify it.”

Mr Prasifka maintained there is plenty “of [anti-bullying] activity on the ground” but he warned that if improvements are not made, then the Council will have to re-look at the situation.

“It is disappointing that the results are not filtering through in the annual survey,” he said.

“All that causes us to do is to redouble our efforts to work more with the training bodies and the stakeholders. The good thing about the Medical Council is that we will continue to occupy this space and we will continue to monitor. We are not going away; if the problem does not improve in the next couple of years, we are going to have to think of more things to do and work harder with the profession to try and get a grip of the problem.”

Your Training Counts report highlights

The average age of the trainee population is 30.56 years.

54 per cent of trainees are female, and over 86 per cent are graduates of Irish medical schools.

36 per cent of trainees experienced bullying or harassment in their training posts, up by 2 per cent on the previous survey.

4 per cent felt physically unsafe in their workplace.

51 per cent felt medical school prepared them well for their intern year, their first time working in a clinical setting.

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