Address by Mr. Micheál Martin TD, Minister for Health and Children, at the publication of the Report of the National Task Force on Medical Staffing
I am very pleased to publish the Report of the National Task Force on Medical Staffing today. Implementation of this report will be an essential element in achieving the kinds of improvements in health care that we want and that each member of the public deserves.
Health service reform
My starting point is to do what is best for patients throughout Ireland. As we take the steps necessary to develop a modern, efficient and patient centred hospital service, making use of the benefits of new treatments, technology and professional skills, we must not lose sight of the value of keeping services at the heart of local communities.
Objective of our health policy
The major objective of our health policy is to deliver access for all to high quality health services. On previous occasions I have outlined how health services have expanded significantly over the past number of years. Today, more people receive care and support services than at any other point in the history of the state.
Activity has increased in every area of the health service. There have been substantial and real improvements in areas such as cancer and cardiovascular care. The health service often gets little credit for these achievements.
In the National Health Strategy we stated that reform of medical staffing and the hospital system was a key component in reforming the delivery of patient care. The Task Force report published today involved a comprehensive evaluation of future hospital medical staffing requirements, the provision of medical education and training and how we can best deliver medical care in our hospitals.
The Government decision regarding the Task Force recommendations completes the package of reforms set out in the Health Service Reform Programme announced in June. It is important to note the consensus between the three reports – Prospectus, Brennan, and now Hanly – regarding the need for reorganisation of both medical staffing and hospital services.
Background to Task Force report
At present, most frontline medical care in hospitals is delivered by junior doctors (NCHDs), most of whom work excessively long hours. Patients have limited access to consultant care. NCHDs will soon be required by law to work fewer hours.
I established the National Task Force on Medical Staffing in February 2002 to devise an implementation plan for reducing average working hours of NCHDs in line with the European Working Time Directive; to assess the implications of moving to a consultant-provided service; and to address the medical education and training needs of doctors in this context.
The Task Force brought together hospital consultants, NCHDs, doctors from general practice and public health, the nursing and midwifery and the health and social care professions, health educators, the medical unions, managers and representatives of the public interest.
During its work the Task Force took particular account of two previous reports: the Medical Manpower Forum and a report chaired by David Hanly on the Working Hours of Non Consultant Hospital Doctors. Both of these were completed in 2001. They highlight a consensus amongst doctors, nurses, health care professionals and managers regarding the need for more consultants, with new work patterns and less junior doctors, working shorter hours.
They also pointed to the need to renegotiate contracts, restructure medical education and training and re-examine how and where we provide acute hospital services into the future.
Findings of the Report
Today, on foot of the Task Force report, I am setting out a programme of action that will enable patients to be treated by a larger number of senior doctors, working within a reorganised hospital system. Patient care will be the responsibility of teams of consultants, supported by junior doctors working safer hours, in an improved training system.
In order to meet the requirements of the European Working Time Directive and to deliver a better service to patients, the report recommends a series of important measures must be taken to:
- reduce the working hours of NCHDs,
- achieve a consultant-provided service;
- reform the current system of medical education and training; and
- reorganise acute hospital services.
Compliance with the Directive will be possible only if urgent measures are taken to meet each of these goals.
Non-consultant hospital doctors have played a key role in service delivery in the Irish hospital system for many years. At present, there are over 4,000 NCHDs in Ireland, delivering frontline services in more than 40 public acute hospitals and numerous other health agencies.
NCHDs work an average of 75 hours a week on-site. In some specialties NCHDs work for considerably longer than 75 hours per week, often for extended periods without rest.
International evidence clearly shows that working long hours seriously affects the health and well-being of doctors and, in turn, the quality of medical care offered to their patients.
From 1 August 2004, these working arrangements will no longer be legally permissible. Under the Directive, the average working hours of NCHDs must be reduced to no more than 58 by 1 August 2004, 56 by August 2007 and 48 by August 2009.
The Task Force has proposed a series of important national measures aimed at reducing the average working hours of NCHDs. The immediate target is a reduction to 58 hours a week by 1 August 2004. These measures include:
- replacement of the present system of “tiered” on-call, by a system offering patients speedier access to the appropriate level of medical care;
- increased use of cross-cover arrangements;
- the introduction of new working and training patterns for NCHDs; and
- a defined set of measures aimed at reducing NCHD workload, with an emphasis on areas in which other staff are better placed to deliver a quality service.
I strongly support these initiatives. Like many key aspects of the report, they will need to be negotiated with the relevant parties, but I believe that they are the best way forward.
There is one measure that the Task Force rightly rejected: the recruitment of extra junior doctors. This would actually worsen the situation for both patients and doctors. We need a greater proportion of senior decision-makers in medicine, not less.
Today, most hospital medical care is provided by almost 4,000 NCHDs and just over 1,700 consultants. This ratio of NCHDs to consultants limits the extent to which consultants can deal directly with patients. Instead, many patients rely on the delivery of care by junior doctors.
Patients must be seen by a doctor who has the skills, training and experience to diagnose, treat and plan their care. I endorse the Task Force’s conclusion that a consultant-provided service is the only way to ensure high quality safe patient care while achieving compliance with the Directive. This will involve consultants working in teams, sharing responsibility for patients with their consultant colleagues.
In order to achieve a consultant-provided service, we require a substantial increase in the total number of consultants and a corresponding reduction in the number of NCHDs. Significant change will be needed in the current consultant contract. Agreement will be required to enable consultants to participate as required in the provision of on-site cover in the hospital over the 24-hour period. There must be clarity regarding the proportion of a consultant’s time that is appropriately spent on clinical and on training commitments. Provision must also be made to enable consultants to play a greater role in management and budgetary decisions.
I believe that these requirements are essential to the development of a genuinely consultant-provided service. There can be no question of moving to this system in the absence of a substantially changed contract. It is vital that the forthcoming consultant contract negotiations reach agreement on these issues.
Medical education and training
Reform of our medical education and training system is a vital component of the new service model. Because medical education and training for NCHDs is intertwined with service provision in our hospitals, we will need major changes in how we deliver and organise medical education and training in a shorter working week. Integral to a consultant-provided service are genuine training posts for all NCHDs. As working hours reduce, training must be delivered without compromising on quality.
There have been positive developments in the provision of medical education and training in recent years but deficits remain. I look forward to speedy implementation of the Task Force´s wide-ranging recommendations in this area, which include:
- integrating training functions currently scattered throughout numerous agencies;
- ensuring that all NCHD posts are for training rather than for services alone;
- top-quality, safeguarded training, oriented to a new model of service delivery;
- a flexible training strategy; and
- measures to address the concerns of non-EU doctors in training.
The Task Force has also recommended a dedicated central training authority. The Government endorsed the need to draw together the various functions relating to medical education and training, but believes that this is best achieved within the reformed health structures announced in June. I anticipate that these functions are best carried out within the Health Service Executive.
The Medical Education and Training Group of the Task Force, chaired by Dr. Jane Buttimer, will remain in place to address a number of outstanding issues, including
- the training implications of the proposed new service model,
- skills deficits which hinder entry of some NCHDs to the specialist register,
- improving graduate retention,
- the role of the university sector in initial and higher specialist training,
- obstacles to the conduct of academic health research, and
- improving access to international training opportunities.
At present, many hospitals depend on NCHDs working long hours to provide a range of emergency, often complex, services. This situation is no longer sustainable in light of the European Working Time Directive, the need to introduce a consultant-provided service and reforms to medical education and training.
What I am announcing today is the beginning of a new way of organising hospital services.
- Firstly I want to emphasise that the Government will not close any hospital, nor does the Task Force recommend the closure of any hospital.
- Secondly, this process is not about ‘downgrading’hospitals. Instead, we need to bring services closer to patients while ensuring that those services are both safe and sustainable. The process will be one of transformation and development. It is about harnessing the strengths of every hospital so that they can best meet the needs of patients.
The Task Force has made detailed recommendations regarding the organisation of acute hospital services in two regions. We also need to look at the rest of the country, drawing on the principles set out by the Task Force. This includes taking geographic and demographic considerations into account.
In recent years, the Government has made substantial investment in our acute hospital services. There is more to do, of course. We need, in particular, to make sure that we provide different forms of care in the right location. We should not expect every single hospital to cope with complex services for which they are not ideally suited. This is no reflection whatever on the staff providing them. But the repeated expert advice to me – from the Task Force, Comhairle na nOspidéal, training bodies and many others – is that we must be very careful to provide certain services in hospitals that have the facilities, volumes of activity and expertise to provide the best possible service for patients. This is about safety and quality. It is not about “downgrading” hospitals, or about taking away services from local communities.
A key part of any reform of our hospital services is a reorganisation of emergency care. The evidence is clear. Patients do better in hospitals that have the required numbers of specialist staff, high volumes of activity and access to appropriate diagnostic and treatment facilities.
At the heart of our reform programme, however, is the recognition that while we need to concentrate emergency care in our major hospitals, reorganisation of acute hospital services offers the potential for a wider range of safe effective, high quality care to be offered in our smaller hospitals.
Those hospitals identified by the Task Force as “Local Hospitals” are ideally placed for that role. In the future, I expect them to provide an increasing volume of elective procedures and the kind of multi-specialist day and outpatient care that is currently performed in the larger hospitals. I believe they should be developed further to provide excellent locally available services to their communities.
No two Local Hospitals will be entirely the same, but the core of their services will include elective medical and surgical procedures, day surgery, minor injury and illness units, high quality diagnostic services, outpatient clinics, pre and post natal maternity services, intermediate care and rehabilitation and convalescence beds.
These would be provided by a group of health professionals including consultants, NCHDs, general practitioners, specialist and staff nurses, radiographers, physiotherapists, occupational therapists and other health professionals.
These services will give people local access to a wider range of hospital services than ever before.
Managing the changes will be challenging. I will not understate the enormity of the task ahead. We must ensure that changes in medical staffing and in our hospitals are linked to developments in the primary care sector as part of the wider process of health reform.
I want to press ahead with the implementation process immediately. In order to reduce average working hours of NCHDs to 58 by next August, we will need an immediate engagement between management and the Irish Medical Organisation. The Labour Relations Commission has accordingly been asked to convene a meeting between both sides so as to agree quickly a process for negotiating the changes required. I envisage that a Working Hours Group, under the aegis of the LRC, would then work intensively to agree on how best to implement the measures proposed in the Hanly report.
Closely linked to this process will be the negotiations on a new contract for hospital consultants. It is clear that we need a new contract arising from the Task Force´s proposals and I am anxious to progress this as a matter of urgency. At my request, the Health Service Employers Agency has written today to the medical organisations in order to arrange an early meeting to discuss the format and terms of reference for the negotiation of a new contract for hospital consultants. My Department and the HSEA will work with the medical organisations to agree an effective and fair contract that helps us achieve reform. It is a vital part of implementing the Hanly report.
I also want to implement the changes proposed by the Task Force in the East Coast and Mid Western regions. To do this there will be a project group in both areas, which will comprise management and health professionals across all of the hospitals involved. These groups will engage in a detailed planning exercise, identifying how best to reconfigure services and staffing at local level.
At national level, the National Hospitals Office will ultimately advise on the reorganisation of hospital services. In order to advance this quickly, I am asking David Hanly to chair a small group which will prepare a plan in line with the principles set out by the Task Force. David Hanly´s group will liaise closely with my Department and, on its establishment, with the NHO.
The project group chaired by Dr. Jane Buttimer which addressed medical education and training issues will remain in place to complete its report as soon as possible.
In a moment, David Hanly will outline the details of these reforms and elaborate on some of the changes required.
I would like to conclude by drawing your attention to four key elements of these reforms:
- Better outcomes for patients in a high quality hospital service
- A large increase in the number senior doctors (consultants) available to see patients quickly and treat them appropriately
- Safer provision of services by NCHDs who will no longer have to work excessively long hours and are part of a reorganised and high quality medical education and training system
- Ensuring that while we begin to concentrate and improve the delivery of emergency care in our major hospitals, we provide a wider range of safe effective, high quality care to be offered in our smaller hospitals.
Thanks chairperson, members, officials
Finally, I would like to thank all those involved in the preparation of the Task Force report, especially the Chairperson, Mr David Hanly, who has invested a considerable amount of time and effort to this complex work. I would also like to thank the Chairperson of the Medical Education and Training Group, Dr Jane Buttimer, the members of the Task Force and the wide range of health care professionals, staff and others who contributed to the Task Force´s consultation process.
From beginning to end, our first concern must be for patients. I believe that the Task Force has set the way ahead clearly, and that its proposals will be to the benefit of all.