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When a specialist is not a specialist

Recently, Mr Justice Peter Kelly criticised the HSE’s recruitment of doctors in the strongest of terms. Mr Justice Kelly, who was speaking in relation to the case of a junior doctor he had suspended from the medical register, said the Executive’s current recruitment strategy is“defective”.

Leaving aside the large number of consultant vacancies, a good example of the flaws in recruitment is the appointment of non-specialists to consultant posts.

Earlier this year, Mr  Justice Kelly had also commented on the practice of employing consultants who were not on the Medical Council’s specialist register in the case of Medical Council of Ireland v Bhatia.

He said that “it is certainly not acceptable that doctors who do not have essential specialist training skills and expertise should be permitted to purport to treat patients as specialist consultants”.

HIQA concern

The IHCA and the IMO have brought up the issue repeatedly. The employment of non-specialists to consultant posts has also attracted the attention of HIQA. On 30 May, HIQA CEO Mr Phelim Quinn wrote to the HSE interim Director General (DG) Mr John Connaghan on the issue, in correspondence seen by the Medical Independent (MI) through Freedom of Information legislation. HIQA had previously raised concerns with the HSE in relation to this matter in August 2017.

Mr Phelim Quinn, HIQA

“The response to this letter, coupled with further information imparted to the Oireachtas Joint Committee on Health on 2 May by the HSE, has not provided the required level of assurance to HIQA that this issue is being appropriately addressed by the HSE,” according to Mr Quinn.

“Indeed, the apparent lack of progress achieved to date raises a concern that an accepted tolerance for this practice has emerged in the HSE.”

He highlighted the recent findings from the case of Medical Council of Ireland v Bhatia, re-emphasising why “this is an unacceptable situation from a patient safety perspective”.

The judgement, which was delivered on 8 May 2018, was directed to be served on HIQA by the President of the High Court. It has also been furnished to other agencies, including the HSE.

“We note and acknowledge that there are ongoing difficulties with the recruitment of certain consultant positions in some specialties and locations,” according to Mr Quinn. “Indeed, this issue was highlighted as a key challenge in our most recent discussions with you and your colleagues in relation to risk identified in statutory Model 3 hospitals. However, HIQA does not accept that these difficulties are insurmountable, and believe that an acceptance of this position should not be tolerated.”

Mr Quinn said he sought assurances from the interim DG that the issue would be “fully and comprehensively addressed”. While he noted that the term ‘consultant’ is not currently a protected term under the Medical Practitioners Act 2007 (see panel), “in the interim of this issue being resolved to its completion, I am writing to also seek assurances from you that measures will be put in place to ensure that patients are informed when they are receiving treatment from someone who the HSE has employed as a consultant who is not on the relevant specialist register”.

Mr Quinn also stated that HIQA intended to engage further with the Medical Council and the Mental Health Commission on the issue. In light of the Judgement, he also intended to write to Justice Kelly to outline what HIQA will do to seek a resolution to the “current unsatisfactory situation”.

Mr Quinn added that as part of HIQA’s impending programme of monitoring against the National Standards for Safer Better Maternity Care, the Authority will be specifically exploring this matter and will publicly report on findings as they relate to non-specialist registered consultants in maternity units nationally.

Mr Quinn said it was important that the HSE respond to these issues within 10 days. However, he sent another letter to Mr Connaghan on 2 July, as HIQA had received no response.

HSE response

On 3 July, Mr Connaghan sent a response to Mr Quinn. Mr Connaghan admitted that there are a number of consultants employed who are not registered in the relevant specialist division of the register. As of 19 June, the number of consultants employed who were not registered in the relevant specialist divisions was 133, which represented 4.5 per cent of the workforce. However, Mr Connaghan stated there may be more consultants working in HSE-funded posts who do not hold specialist registration and that the matter needed to be examined.

He explained that, in effect, there are two separate cohorts of doctors in terms of their tenure in the HSE. There are those employed on a permanent basis prior to 2008, and those post-2008 with a contract of indefinite duration, and those employed on a temporary/locum basis, either in a specified purpose/fixed-term contract or employed through an agency. In terms of the first cohort, Mr Connaghan wrote there were 51 consultants in permanent employment who took up posts before the introduction in 2008 of the contractual requirement to be registered in the relevant specialist division. A further 10 doctors were employed post-2008 and have now acquired a contract of indefinite duration. Regarding the second cohort, there were 72 consultants currently employed who took up post since the introduction in 2008 of the contractual requirement to be registered in the relevant specialist division.

Practical steps

Mr Connaghan stated how Director of National Doctors Training and Planning (NDTP) Prof Frank Murray has convened a working group of stakeholders to address the issue. The group includes representatives from the Medical Council, the Forum of Irish Postgraduate Medical Training Bodies, and from various arms of the HSE. A cohort analysis had been completed using the NDTP DIME database, which identifies the relevant consultants on the general division for each Hospital Group and Community Healthcare Organisation (CHO) by their location and specialist, the date of appointment, the type of tenure and their anticipated retirement date.

“In respect of the pre-2008 consultants, the expectation is that in many, if not all instances, their prior career training and experience may have entitled them to obtain registration on the specialist division on or immediately after securing their permanent appointment,” according to Mr Connaghan.

“The HSE therefore wishes to encourage and support these pre-2008 consultants to seek specialist registration now, and to support them in a number of ways.”

Prof Murray’s working group was exploring, with the Medical Council and the Forum, a means of “facilitating and expediting” the application process for inclusion on the specialist division for the pre-2008 consultants, having regard to the varying lengths of time that will have elapsed since they took up post. The HSE agreed to pay the Medical Council directly for the cost of application for registration so that no pre-2008 consultant applicant need incur any cost.

Post-2008 consultants were to be advised that specialist registration will be required as part of continuing appointments.

“The same financial support may be available to them, with the cost of the application process being met directly by the HSE in appropriate cases,” Mr Connaghan outlined.

“Pending the acquisition of specialist registration, there is a need for a risk assessment and a satisfactory safety framework to be put in place for the continuance in post of any of these consultants in the general division.”

The letter also outlined how the working group is considering other guidance that it intends to issue to Hospital Groups and CHOs on other aspects of the issue of consultants not registered on the specialist division. This included a directive to be issued by the interim DG prohibiting the employment of any further consultants on the general division. There was also the need for hospitals and CHOs to have a risk stratification process and safety framework differentiating the approach to permanent pre-2008 consultants of long-standing employment at one end of a continuum, and recent post-2008 consultant appointments at the other end.

Current situation

A spokesperson for the Authority told MI: “HIQA continue to engage with the interim Director General in relation to this matter, and it is intended that we will include checks to verify that the commitments made to address this matter as part of our standard inspection activity over the coming months”.

Also speaking to MI, National Director of Human Resources with the HSE Ms Rosarii Mannion said that the focus is on doctors employed post-2008, when specialist registration became a requirement for employment in a consultant post.

“A team has been established and that team is looking at each individual consultant that is employed and trying to put a personal development plan around each individual consultant,” she stated.

To date, two-thirds of site visits by the team have been completed.

Ms Mannion said it may be that a doctor meets the requirements of specialist registration but has not applied, but in other cases, it is about identifying what is required and whether there may be gaps in training, for example.

For those doctors who do not meet the requirements of specialist registration, “then clearly, we’d be looking at different measures”.

A directive has also been issued by the interim DG which prohibits appointments of further consultants not on the specialist register, unless escalated for “exceptional approval”. 

The Medical Council has written to the HSE, setting out the requirements for doctors to be registered in the specialist division.

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