Friday, 30 June 2000
Seanad Eireann Debate
Minister of State at the Department of Health and Children (Dr. Moffatt): I commend to the House the Medical Practitioners (Amendment) Bill, 2000, which provides for the temporary registration period, as set out in section 29(2) of the Medical Practitioners Act, 1978, to be extended from an aggregate period of not more than five years to an aggregate period of not more than seven years. It is intended to do this to ease recruitment and retention difficulties being experienced by hospitals in relation to non-consultant hospital doctors. From 1 July, some hospitals will experience difficulties in securing their required number of junior doctors. This amendment will remove one of the obstacles in that it will allow doctors who may have to leave the country to remain here and thereby ease some staffing difficulties.
The staffing requirements of hospitals and the deployment of staff within hospitals is primarily a matter for local management, having regard to the services which hospitals are expected to provide. There are particular staffing difficulties being faced by the health services at present across a wide range of areas, particularly in medical, paramedical and nursing areas.
This amendment to the Medical Practitioners Act is one of a number of measures being taken to improve the working arrangements for non-consultant hospital doctors. On a broader front, the issues relating to medical staffing of hospitals are currently being addressed by the Medical Manpower Forum. With particular regard to non-consultant hospital doctors, the forum is seeking to redress the imbalance between career posts and training posts, the need to improve post-graduate medical training to keep more Irish medical graduates in the country and the need to examine the position of women in medicine in Ireland with a view to redressing the number who leave medicine. The Medical Manpower Forum is due to finalise its first report shortly.
An intensive series of negotiations held under  the auspices of the Labour Relations Commission has concluded and agreement has been reached with the Irish Medical Organisation on all the major concerns of non-consultant hospital doctors. The proposals are now being balloted on by the NCHDs. As the NCHD committee has recommended that the proposals be accepted, I am hopeful that the industrial action threatened is now resolved.
The proposals for settlement include a very significant improvement in the overtime rates being paid to NCHDs. In addition, a senior manager is to be appointed in each major hospital with specific responsibility to manage NCHD hours. A concerted effort is to be made to improve the working conditions and to reduce NCHD working hours with particular attention to long periods of continuous duty. There is also a substantial training package to be put in place amounting to £10 million per annum. New procedures are to be put in place to deal with NCHD grievances at local level. Relocation expenses are also to be paid to NCHDs who have to move residence as part of formal rotation schemes.
Some of the issues that affect the working conditions of NCHDs cannot be resolved immediately. Among those are the twin issues of working hours and the restructuring of the medical career hierarchy. The working hours of NCHDs have been the subject of negotiations at European level in the context of the proposed extension of the 1993 EU Directive on Working Time to doctors in training. Deputies will be aware that different stances on this issue have been taken by the Council of Ministers and the European Parliament. I am glad to note that the agreement was reached on a formula that provides for a nine year transition period to apply the directive to junior doctors. Ireland has always stated that it will reduce junior doctors' working hours to an average of 48 per week at least as quickly as required by any European legislation, if not sooner. I am confident that, with the full co-operation of the profession, we can achieve that objective in the nine years allowed or in a shorter period.
As part of our preparations for this eventuality, we are conducting a major study of NCHD working hours on a joint basis with the Irish Medical Organisation. The study is being undertaken at eight hospitals by PA Management Consultants. The report of the study will be available shortly.
In relation to the non-consultant hospital doctors staffing shortages, health service employers and the Health Service Employers Agency are continuing to monitor the take up of employment offers made from 1 July 2000. As an NCHD may have an offer of employment from more than one hospital, the full picture will not emerge for some days. However, I expect further positions to be filled after 1 July. Hospitals are exploring different options in an effort to ensure that essential posts are filled. In the event that some posts remain unfilled, hospitals will be asked to ensure that essential and critical services are not affected. With the full co-operation of all  concerned and a commitment to making the best use of available resources, the effect on services can be minimised.
While the primary responsibility for the staffing of hospitals rests with hospital management, I seek the co-operation of this House to amend the Medical Practitioners Act, 1978, to extend the period of temporary registration for NCHDs from five years to seven years.
Mr. Doyle: I welcome the Minister of State to the House. While this area is not my brief, I have some knowledge of the difficulties existing in hospital services, especially the junior hospital doctors issue, as I am a member of the ERHA and the East Coast Health Board. This problem has developed over many years. A Private Members' motion was tabled recently by Senator Henry on the matter. This problem persists and, thus far, there is no light at the end of the tunnel. However, I hope what the Minister of State said will give us some assurance that the current industrial relations difficulties will be resolved.
If we are to have a good medical service, we must have junior doctors who are happy in their employment, work reasonable hours, get well paid and are provided with other essential services, such as accommodation near the hospital, but that is not the case at present. As a medical practitioner, the Minister of State must be conscious of the difficulties relating to junior doctors and the long hours they work, a practice which has a long history.
This is a short Bill to allow the Minister to extend the temporary registration of non-EU doctors from five years to seven years. That will allow doctors whose registrations will expire on 1 July to continue to work in our hospitals. However, given that today is 30 June, this legislation is being introduced a little late in the day. Non-EU junior doctors whose registrations will expire tomorrow will have made other arrangements. This legislation will provide us with no more than 25 non-EU junior doctors who will be able to continue to work in the State. While that will be an improvement, I hope the Government gives a commitment to address fully the problem of the shortage of junior hospital doctors.
In reply to a question in the Dáil on 23 May, the Minister of State at the Department of Health and Children said there was no evidence that there will be a shortage of junior doctors arising from the new assessment for non-EU doctors, while on 30 May, the Minister for Health and Children gave a different reply. He acknowledged that some hospitals were experiencing some difficulties in recruiting junior doctors in certain specialties. Those hospitals are experiencing grave difficulties in recruiting such doctors. There is no doubt there is a problem in the health services with junior doctors and I hope what is proposed will address it.
 Given that many people with minor problems go to accident and emergency departments, much of the time of the staff in those departments is taken up dealing with patients who could be dealt with elsewhere. The East Coast Area Health Board, in conjunction with St. Vincent's Hospital, is making arrangements for a general practitioner to be available on the campus of that hospital from 6 p.m. to 11 p.m. each evening to deal with patients who wish to see a GP. General practitioners in the area have got together and agreed to participate in this initiative, which will reduce the pressure on the accident and emergency department in that hospital.
I hope the Minister of State will encourage the introduction of similar initiatives throughout the country. Such an initiative could develop further than the GPs dealing with patients with minor problems and that would reduce further the pressure in accident and emergency departments, as that where the real problem lies.
I deviated from the Bill in making that point, but given that this initiative was announced recently and will be introduced shortly, I thought it was worth mentioning. I urge the Minister of State to consider introducing similar initiatives in other areas.
Mr. Glynn: Cuirim fáilte roimh an Aire Stáit go dtí an Teach. I strongly support this Bill. The two extra years of extended registration is a significant step in resolving difficulties related to the recruitment of junior doctors. I am pleased the Minister of State referred to the long hours that junior doctors work. As someone who worked with them for many years, I often wondered how they could carry out their duties having worked so many hours. Given that proposals have been agreed between the Labour Relations Commission and the IMO, which are currently being balloted on by the NCHDs, and that the NCHD committee has recommended that the proposals should be accepted, it would be wrong for me or any other Senator to say anything that could affect the outcome of that ballot one way or the other.
I welcome this Bill which is significant in terms of what it provides. The Minister of State has said all that needs to be said. The provision of £10 million per annum for training is significant. Junior doctors, as with every other profession, must have a facility whereby they can improve their career in a structured way. I welcome the Bill and I trust it will have the support of the House.
It says a lot that when the new Minister for Health and Children went into the Department he immediately had to set up an industrial relations initiative. It is extraordinary that the health service employers have had a nurses' strike and have just, perhaps, averted a non-consultant hospital doctors' strike. I asked on the Order of  Business this morning if we could find out what has happened to home helps who appear to be in difficulty again with the health service employers. People who were paid ridiculous sums, such as £3 per hour, for keeping the elderly in their homes will now be granted £6.50 per hour, but apparently some difficulties have arisen with the health service employers. Someone has got to be in charge of the health service employers. If it is not the Minister for Health and Children we should be told.
I was saddened on the last occasion I raised this topic in Private Members' time two weeks ago when the Minister said we could not require statutory health boards to be independent and at the same time expect him to do something. He has overall charge of the health services and if we cannot look to him for help, to whom can we look?
No progress has been made on the negotiations with the consultants. The Minister of State will say the medical manpower report is due shortly but we had the Tierney report five years ago which seemed very good. The medical manpower report will not be agreed shortly because the Irish Hospital Consultants Association has not agreed the sub-consultant grade, nor will it. The Department may want it but it has been a dismal failure in Great Britain. Why would we want to introduce something here which has been such a failure there? Let him introduce sessional consultants, part-time consultants if he wishes, but he must get rid of the notion that this sub-consultant grade, which in many cases would take the place of additional consultants, would be a great help. I hope the Minister of State, Deputy Moffatt, will convey these views to the Minister, Deputy Martin.
Non-EU doctors here have been treated disgracefully for many years. They have been the backbone of the health service, particularly outside Dublin, Cork, Galway and Limerick. They have run the county hospitals of Ireland. They came here for training which they did not get. This is the reason the Medical Council acted in 1996. I have been raising this matter since 1997 and advised that this day would come. Now it has come. The previous Minister for Health and Children took no notice of what I said. The Medical Council said it had to do something because of the lack of training in various county hospitals. That is due to a lack of consultants. Naas General Hospital has one anaesthetist consultant on duty at a time. It shares consultants with Tallaght Hospital. Naturally it could not make an agreement in regard to the training of anaesthetists there, so how could the casualty department take it on?
There are two obstetricians working here single handed. They are the last two in either the United Kingdom or this island. There are nine hospitals which have two consultants. The Institute of Obstetricians has said, while there is six months to go, it will not sanction training posts in those  hospitals. What preparations are in hand for this eventuality? It is incredibly disappointing.
Another shabby practice for non-EU doctors was that if they left the country to go to, say, a seminar in London they were charged for a re-entry visa. One Russian told me he had to pay £50. Was that not a great way of encouraging non-EU doctors to keep up our medical staffing? It is no wonder they have left. When the Medical Council made its regulations it also said that non-EU doctors had to do an examination before they could become accredited to work here. This was fair. However, in the past they did not have to do an exam. They could work here without doing an exam, while to work in Great Britain they had to have an exam. The cost of coming here was prohibitive for them. Instead of 200 or 300 coming every year only ten to 20 came. Given that I have raised this matter so many times I do not know why I am even discussing it again. This was bound to happen. Here we are on 30 June and the crisis will start on 1 July.
While the inadequacy of the training programmes will not be addressed by £10 million, that sum is welcome. We have got to have consultants who have time for training. They are the individuals who train these people but they are running ragged from trying to keep the health service in operation. We are 1,000 consultants short of the number needed to get us up to Scottish levels. I do not think anyone has said the Scottish levels are excessive.
Senator Glynn said the other day there was a rheumatology programme in the Midland Health Board. I asked him afterwards who was the rheumatologist. He then explained that it was the hope of the Midland Health Board to have a rheumatology programme. The Midland Health Board deserves three to four rheumatologists but there are only about ten in the country. It is utterly ridiculous that there is such under representation of people in medial specialties, in particular neurologists. How many times have I told the House we have 11 when we should have 35?
Senator Chambers called for a policy on strokes and more action on them. How can we have any action without some neurologists? On the issue of rheumatologists, do we not have arthritis in this country? Then there is the most serious problem of ophthalmology. The Lions Club pays for people from the Midlands Health Board, who have been on the waiting list for over two years, to come to Dublin overnight so that they can have day surgery for cataracts. While the country is supposed to be awash with money and the Minister for Finance is telling us to party this is what is being done to those who are blind.
There was the recent scandal about the 78 year old locum who had been working as a pathologist in Letterkenny Hospital and Tralee General Hospital. It was a minor miracle that we were able to get a 78 year old to work anywhere. There are more consultant singlehanded posts in the country than proper set-ups. How can these people get even a day off if they do not manage to  get a consultant from somewhere? I agree there should be some regulations regarding who can be appointed to consultant posts. As my colleague, Professor Sean McCann, wrote to The Irish Times, how would you feel if you were told that a 78 year old locum pilot was flying you across the Atlantic? Not too happy, I would imagine. We were fortunate to get somebody to take these positions. Not only are there far too few consultants on the ground but when anything happens we are in a dire situation.
The Medical Council sees what is happening with the General Medical Council in England. It is not supposed to be in charge of staffing but rather standards. It cannot be held responsible for a decrease in staffing if it is trying to raise standards.
Whenever there is a problem here there are angry patients and their public representatives are also angry. I was very upset this morning when Senator Liam Fitzgerald said on the Order of Business that he would like a course held on communication and an improvement in manners, although he was kind enough to say bedside manners, for consultants. When I raised this with him subsequently he did have cause for complaint. I suggest that those who are working in the hospitals are working on the run and under ridiculous conditions. Senator Glynn has said he cannot understand how the junior hospital doctors have managed to give a service in some situations, and he has seen the problems in the psychiatric services which are acute. He has not spoken much about the shortage of non-consultant hospital doctors but it is an important issue. The position with consultants is very bad. At certain times there would not even be an office into which one could take a patient to try to speak to them about something private; everything would take place in the middle of a clinic. I can understand Senator Fitzgerald's annoyance with the complaints that have been made to him and I will certainly take them up.
There have been such scandals in Great Britain that members of the General Medical Council yesterday took the serious step of voting for the disbanding of the body because they felt that as a regulatory body it had not been vigilant enough regarding members. They were right. We have only to look at the heart operations which for years were carried out on babies in Bristol where there was a totally unacceptable mortality rate. For several years the anaesthetist who pointed out the deficiencies in the service was not well supported by his own discipline. Indeed, he emigrated to Australia for a more peaceful, if not better, medical life because he believed his prospects of promotion would be diminished in Great Britain because of his whistle blowing. Perhaps there is something to be said for the criticisms of patients that people who work within the service are not fast enough to criticise colleagues.
The General Medical Council now has serious problems because of Dr. Shipman, who killed  goodness knows how many people, and Dr. Ledward, whom women say mutilated them over his 18 years of operating. He is now able to work in Ireland as a pharmacist and could well be working as a locum pharmacist. The Pharmacy Acts contain no provision for a fitness to practise committee. Would that not be a new issue to tackle in the autumn? There were other consultants and general practitioners in England who did serious damage before their paths were arrested.
The key to solving the problem in this area is the appointment of more consultants to ensure training in posts where there is currently none. The Minister of State concluded his speech by saying, “With the full co-operation of all concerned and a commitment to making the best use of available resources, the effect on services can be minimised.” What does he mean by that? I would have thought that all we can do is consolidate services. Navan, Cavan, Monaghan and Drogheda have serious problems regarding anaesthetists. The Minister of State, Deputy Moffatt, will be aware that it is unsafe to run a casualty department without anaesthetic cover. People should be told that certain hospitals are closed for accidents and emergencies until the situation is sorted out.
We are now in the holiday season, which means there will be locums in hospitals who are not familiar with those hospitals. I am aware that efforts are being made to recruit abroad and that the Internet is being used to search for German doctors, for example. However, the Department will have to assess them and ensure they speak adequate English. It will take some time for the accreditation processes to be completed.
There has been a terrible lack of a sense of urgency in the Department of Health and Children in the last few years. It takes at least a year in the voluntary hospitals and longer in local authority hospitals to fill a consultant appointment. Why does this process begin at the time the resident consultant is retiring? Why does it not begin a couple of years prior to that? That is what happens in most health services and in some it is considered desirable for the incoming consultant to work for six months with the consultant who is in place. That system could be introduced immediately. One need only look at the age range of employees and start filling the replacement posts at once.
A total of £10 million is being spent on the waiting list initiative. Who will operate on the patients? Surgeons from different hospitals have contacted me to tell me, for example, “I played golf on Monday to deal with my anger; I had to cancel my list because no anaesthetist was available.” In another hospital, one of the major teaching hospitals in Dublin which shall be nameless, there is such a shortage of anaesthetists that, to ensure fairness, the surgeons operate a rota to determine who will have to cancel a list. Is this any way to run a health service?
Introducing legislation such as this is like running a health service with bits of Elastoplast. I  cannot welcome it because I do not believe it will do any good. I doubt that any of the non-EU doctors, who might have been induced to stay if they had been approached three or six months ago, are still in the country. Why stay here if one knows one will be treated in this manner?
Minister of State at the Department of Health and Children (Dr. Moffatt): I thank Senators for their contributions. Senator Joe Doyle is a member of the ERHA and is aware of what is happening at NCHD level. He recognises that there are difficulties, as does the Government, even if it was slow to react. That is a fair criticism but at least the Government is reacting and, hopefully, its reactions will be of benefit.
I accept Senator Doyle's comments about St. Vincent's Hospital. The practice of GPs working there should be of benefit. Throughout the country hospital administrators are inviting GPs to run such a service. It will alleviate problems in accident and emergency departments. Senator Glynn said the extension of the time limit from five to seven years should be useful. He commented on the long working hours, which has been a hobbyhorse of Senator Henry's for some time. She is absolutely correct. It is time this matter was straightened out. I am still not happy with the EU directive on it. We will make progress, however. The Minister, Deputy Martin, is approachable and far seeing. He knows that things cannot be put on the back burner forever. We must confront our problems.
It is a short Bill but, hopefully, it will be significant. Senator Henry addressed the Bill to some extent and then went on to deal with other matters. I cannot disagree with most of what she said. However, it takes time to solve problems in the health sector. Throwing money at it is not the answer. The Senator drew our attention to problems with regard to nurses, NCHDs and home helps. I am disappointed to hear about the home helps.
Dr. Moffatt: The minimum wage increased salaries to at least £4.40 per hour so we thought there would be progress. When we came into office the salary was as little as £1.50 per hour in the Southern Health Board, so it has increased a good deal. We recognised there were problems in that regard and I hope they will be straightened out. The Senator referred to offers of up to £6.50 but the issue might not be money. There might be other issues.
Dr. Moffatt: I agree that we have not treated non-EU doctors well. The pressure is on us now, however, with our own doctors emigrating, particularly our anaesthetists. It is a pity that of the 20 who qualify each year, only five remain in the country. That will have to be tackled. The £10  million for further education and training will help. It is a move in the right direction.
Dr. Moffatt: The Senator is correct. We will need more consultants. It was never the intention, in regard to the appointed subconsultants, that they would be in any way inferior in their qualifications. They were consultants. It is unfortunate that the term “subconsultants” was used at all. I do not wish us to follow the English practice—
Dr. Moffatt: That is right. There is a problem appointing consultants. It takes too long and we do not act in time, especially when numbers are increasing. There is a problem with Comhairle na nOspidéal and the Local Appointments Commission – we have pointed that out and it has been pointed out to the Minister. The Senator has also referred to it. There is no reason that cannot be fast-tracked and if we are to make progress, we will have to do that. There is no way around it.
There are problems with obstetrics and gynaecology. I hope the manpower forum will arrive at solutions in that regard. I see some hope of getting three instead of two into the peripheral hospitals. There will have to be a minimum of three if we are to abide by the council's direction. That will have to be addressed also. It has been estimated that the number of consultants that will be required is between 800 and 1,000. We will make an attempt to achieve that. It will take a number of years but we must make a start if we are to achieve the high standards people demand and they have a right to demand such standards.
Dr. Moffatt: That is a start in the right direction and if it can be done there, there is no reason it cannot be done in other specialties. There is some controversy today, however, at University College Hospital, Galway about a professor who is due to be appointed because ní raibh Gaeilge aige. Sin scéal eile. He is an excellent person.
We must be vigilant in relation to scandals and take cognisance of what the Medical Council has said. As the Senator has already said, it is not all one way traffic in relation to Dr. Shipman and Dr. Ledward.
I would not like to see hospitals or accident and emergency departments closing down. I have been talking to people in charge of smaller hospitals throughout the country who have been  co-operating with consultants in order to continue a service which is of the highest standards. It is vital that high standards are provided.
A number of measures are being taken to improve the conditions for NCHDs and the service in general. I am pleased the threatened industrial dispute will probably be called off. I live in hope. The 48 hour working issue for NCHDs will have to be taken off the agenda, and the sooner the better.
I thank Senators for their contributions. Health is always of interest and we probably do not pay sufficient attention to it. We put matters on the back burner and sometimes issues must go wrong before we address them. I thank Senators for pointing out many issues and I am sure the Minister will take cognisance of what has been said. I am aware that Senators do not want to waste their time making contributions and pointing out deficiencies unless some of them are taken on board. Everything cannot be done overnight but we value Senators' comments.
Dr. Henry: I am serious about the issue of accident and emergency departments not being adequately staffed. For example, if one has a serious car accident and is brought to a hospital where there are inadequate staffing levels, it is much worse than taking an extra 20 minutes to travel to another hospital.
Mr. Glynn: I thank the Minister of State and Senator Henry. As the Senator has said, I accept there are problems in relation to accident and emergency departments. I have raised this issue at health board level. However, very often the problem is caused by people by-passing their general practitioners and going to accident and emergency units. These people should go to their general practitioner. As a general practitioner, the Minister of State will be aware of another problem. Because society has become so litigation conscious—
Mr. Glynn: I ask the Minister of State to take these important issues on board because the resources of accident and emergency units are being wasted by people who should be attending their general practitioner.
Mr. J. Doyle: I thank the Minister of State for coming to the House and replying to Senators, particularly Senator Henry who is an expert in the area. I recently witnessed a situation where a  consultant was present in an accident and emergency unit and patients were dealt with much more quickly than when he was not present. Senator Henry has made a plea for extra consultants. I would like some of these consultants to be appointed to accident and emergency units.
Minister of State at the Department of Health and Children (Dr. Moffatt): I thank Senators for their remarks. Extra consultants are being appointed to accident and emergency units throughout the country and I hope this will bear fruit in the short term. The Senator is correct that it makes a big difference if a consultant is present. The teaching element is also important. I will take on board the views of Senators.
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