5.2 Human resources
5.2.1 Number of health care personnel and trends
Table5.6 provides an overview of whole-time equivalent (WTE) employees within public health services in Ireland as at December 2006. Across all sectors there were 106 273 WTE employees, of which approximately one third were nursing staff, while management and administration accounted for over 16%. Overall employment has increased by 56.7% since 1997, with the largest increases being in the employment of ancillary paramedical health and social care professionals. Table5.7 provides information on the geographical spread of health care personnel, which indicates that most HSE staff are in the Eastern and Southern Areas, while an additional 22.9% of all staff are employed by voluntary hospitals, most of which are located in Dublin (Eastern area).
Overall the number of all physicians in Ireland per 100 000 population is low by western European standards, at 292 compared with 331 in the EU15 in 2006 (see Fig5.3). However, the number of physicians per 100 000 population has been increasing steadily since the late 1990s, from a rate of 213 in 1997. This is consistent with trends seen in many other European countries.
There are approximately 2750 GPs in Ireland, of which 2515 are members of the ICGP and thus are included in OECD estimates of doctors per 1000 population. In Ireland this figure was 0.5 in 2005 (OECD, 2007b). This is the lowest rate reported in the OECD countries and compares with 0.7 per 1000 population in the United Kingdom, 0.8 in Norway, 1.0 in Germany, 1.7 in France and 2.1 in Belgium.
In December 2006, 2315 GPs were participating in the GMS Choice of Doctor Scheme, and thus were providing services for all Category I patients (HSE, 2007g). This includes 220 GPs outside the GMS scheme, who were registered to provide services under the Primary Childhood Immunization Scheme, the HAA of 1996 and the Methadone Treatment Scheme (see Table5.8).
An increasing proportion of the GP workforce is female (around one third), which may have long-term implications for working arrangements and practices, demanding greater flexibility (Graham & De La Harpe, 2004). The GP workforce is also ageing. A survey conducted in 2000 by the ICGP reported that the number of GPs aged between 26 and 35 had fallen from 17% to 14%, while those aged between 45 and 55 had increased from 29% to 35% (Payne, 2001). This change in the workforce is occurring at a time when there is a need to increase the number of active GPs if the goals set out in the Government’s Primary Care Strategy are to be attained. Consequently, in September 2003 the ICGP urged the Government to make working conditions more attractive and to invest more resources in general practice (Shanahan, 2003).
Consultants and non-consultant hospital doctors
In December 2006 there were 2096 WTE consultants (specialists) in Irish hospitals and a total of 2144 approved permanent consultant posts. This represents a 60% increase since 1997, when only 1310 WTE consultants were in place, but is still far lower than the number of NCHDs,18 estimated at 4648 (DoHC, 2007c) (Table5.9). The number of additional consultant posts approved by the NHO between 2000 and 2006 was 704, compared to just 345 over the period from 1987 to 1999 (HSE, 2007a). However, the number of NCHDs in post over the period 1997 to 2006 increased by 64.6%, a slightly greater rate than that for consultants.
Both the Hanly Report (2003 National Task Force on Medical Staffing) (Hanly, 2003) and the 1993 report on Medical Manpower in Acute Hospitals (the Tierney Report) called for a significant increase in the number of consultant posts while substantially reducing the number of NCHDs. While consultant posts have increased, there has been no decrease in NCHD posts and in fact they have increased by more than 1000 since 1998 alone. Indeed, the number of NCHD positions increased at a slightly higher rate than that of consultant posts during 2004. However, in 2006 an additional 188 consultant posts were approved, of which 125 were new posts and 63 replacement posts. This was the highest number of additional consultant posts ever approved in one year. Yet, while the number of consultants has increased, they still represented just 31.08% of total medical staff in 2006, still below the rate seen in 1997.
Fig5.4 shows the trend in the number of additional approved consultant posts between 1987 and 2006. In 1996, the consultant-to-population ratio was one consultant per 2800 individuals, dropping to one consultant per 2000 individuals at the time of writing. There has been virtually no change in the geographical distribution of consultant posts since the late 1980s and 48% of all consultants still work in the Eastern region of Ireland. This is unsurprising, given that this is where most of the voluntary hospitals and specialist national services are provided (see Table5.10).
Table5.11 provides information on consultants by specialty as at December 2005. The increase in consultant posts by specialty since the turn of the millennium has not been even, and specific national strategies – such as that for cardiovascular diseases – have influenced the number of specialist posts created. In particular, the NHO noted in 2004 that a substantial number of specialists in obstetrics and gynaecology were required (Comhairle na nOspidéal, 2004). Some specialty groups, for example, biochemistry (for which there are five posts) and genito-urinary medicine (two posts) had no consultants at the end of 2005.
The average age of new consultants taking up appointment in Ireland remains high. In 2003 it was 39 years and in 2004 it was 40 years of age. There has been a gradual change in the proportion of male and female consultants from 87% male, 13% female in 1990 to 74% male, 26% female by 2005. In 2003, 62% of new consultants were male and 38% female.
An Bord Altranais (the Nursing Board) has legislative responsibility under the 1985 Nurses Act for the registration of nurses in Ireland. This includes a number of different disciplines: general, midwifery, psychiatry, sick children, public health, intellectual disability and tutors. The Board is required to assess every five years the adequacy and suitability, effectiveness and efficiency of hospitals and institutions for nurse training, and to ensure that all Board regulations and European Directives are complied with.
In 2002, the Pre-Registration Programmes in General Nursing (RGN), Psychiatric Nursing (RPN) and Mental Handicap (Learning Disability) Nursing (RMHN) were offered for the first time at university degree level. The successful completion of the 4-year degree programme leads to registration with the Nursing Board (RGN or RPN or RMHN) and the award of a Bachelor of Science (BSc) Degree in Nursing from the higher education institution. A total of 13 institutions, in association with 45 health care agencies, offered 1640 places in 2002. In 2006 new direct entry undergraduate midwifery and children’s nursing degree programmes were introduced. The direct entry midwifery programme offers 140 places per annum and the integrated children’s/general programme offers 100 places per annum. Since 2006 there has been an annual intake of 1880 students (see Table5.12).
A working group with representatives from nursing unions and health service employers, as well as officials from the DoHC, was established to address two very important recommendations of the Commission on Nursing relating to the effective utilization of the professional skills of nurses and midwives (Commission on Nursing, 1998). One recommendation was that the health service providers and nursing organizations examine opportunities for an increased use of care assistants and other non-nursing staff. The working group recommended that the grade of Health Care Assistant be introduced as a position within the health care team to assist and support the nursing and midwifery functions. The recommendation was endorsed by the MoHC.
A review of prescribing and administration of medicinal products by nurses and midwives also took place. This included the evaluation of 16 pilot initiatives in a variety of health care settings for nurse and midwife prescribing. Following this successful pilot, on 1 May 2007 the Medicinal Products (Prescription and Control of Supply) Regulations Amendment (Statutory Instrument (SI) 201 of 2007) and the Misuse of Drugs Regulations of 2007 (SI 200 of 2007) were enacted. These instruments provide the legal authority for nurses and midwives to prescribe medicines and some controlled pharmaceuticals in certain circumstances. Nurses/midwives must be employed by a health service provider, and the medicinal product must be one that would be given in the usual course of the service provided. A new division on the Register of Nurses has been established for nurse prescribers. Registration and education requirements include a stipulation that the nurse/midwife must have three years of post-registration clinical experience and must undergo a further education programme of six months’ duration with theoretical instruction of no less than 168 hours and a clinical component of at least 96 hours. The Royal College of Surgeons in Ireland (RCSI) and the University of Cork provided the first programmes for 52 students from April 2007. To maintain registration authorization, nurse prescribers will have to demonstrate evidence of continued competence; An Bord Altranais is developing this process at the time of writing (An Bord Altranais, 2007b).
In 2006 there were a total of 78 552 registered nurses (including those working in the secondary care sector) in Ireland, of which 62 639 were active. Approximately 8% of all nurses are male (An Bord Altranais, 2006b). After general nursing, midwifery and psychiatric nursing are the most common specialisms (see Table5.13). Since the late 1990s the number of nurses registered in Ireland has risen sharply and in 2005 was well in excess of that seen in many other European countries (see Fig5.5). However, some caution should be exercised when considering these figures: in 2006 it was estimated that the total number of active nurses was 52 600, as not all nurses are working in either the public or private health sectors (DoHC, 2008d).
Although there were more than 9470 active registered psychiatric nurses in Ireland in 2006, it is estimated that over 65% of psychiatric nursing personnel in public service are aged 45 years or over and only 14% are under the age of 34. This may suggest a serious shortage of psychiatric nurses in the near future. The FÁS Healthcare Skills Monitoring Report (2005) projected a demand for 6829 psychiatric nurses in 2015, whilst predicting that there will be a national supply of 6694 psychiatric nurses, resulting in a projected shortfall of 135 nurses (Foras Áiseanna Saothair, 2005).
By the end of 2005 there were 234 consultants in adult psychiatry across the country, compared with 185 in 1991. At the start of 2005, there were 21 consultants of “old age” in psychiatry in Ireland, the first only appointed in 1989. Forensic mental health services are limited, with resources concentrated in the eastern HSE area at the Dundrum Central Mental Hospital. Two special interest posts in the Mid-Western (Limerick) and Southern (Cork) regions have been set up. The postgraduate training programme used by the Royal College of Psychiatrists in the United Kingdom is still used in Ireland, although it is tailored by the Irish Psychiatric Training Committee to meet local conditions.
Although theoretically, anyone in Ireland with the necessary qualifications can set up as a pharmacy, in practice access is strictly controlled, as it is necessary to have a community pharmacist contract with the HSE in order to make a business viable. A total of 1530 pharmacies had public contracts at the end of 2006 (HSE, 2007g). By the end of 2007, in total 1621 pharmacies – including 60 based in hospitals – were registered with the Pharmaceutical Society of Ireland.
Prior to 1996 a pharmacist19 could apply to the Health Boards to open a pharmacy under the terms of the 1970 Health Act, and different Health Boards took different approaches to assessing applications. In 1996 a formal contract application system was introduced as part of an agreement with the Irish Pharmaceutical Union. New procedures took into account population size, catchment areas and the impact on the viability of existing pharmacies. Following a critical external report, Regulatory reform in Ireland, published by the OECD (OECD, 2001), the Pharmacy Review Group was set up in 2001 to review these regulations, with a particular emphasis on maximizing competition within the sector. Of the 1268 pharmacies operating in 2001, 74% were owned by companies (Pharmacy Review Group 2003). However, the market was still fragmented; the largest operator Unicare/Gehe had only a 4.3% share of the market (52 outlets), followed by Boots PLC 2.3% (28 outlets) and the McSweeney Group 1.8% (22 outlets) (Indecon International Economic Consultants, 2003). Subsequently, the Health (Community Pharmacy Contractor Agreement) Regulations of 1996 (SI 152 of 1996) were revoked in January 2002. However, EU derogation rules introduced in 1987 still applied to pharmacists wishing to practise in Ireland, making it impossible for pharmacists, including Irish citizens educated in other EU or EEA countries, to own, manage or supervise a pharmacy that is less than three years old.
An independent review prepared for the Pharmacy Review Group in 2003, including a survey of 427 pharmacists, indicated that there was a shortage of pharmacists, with 59.5% of respondents indicating that they had difficulty in filling posts for community pharmacists (Indecon International Economic Consultants, 2003). Yet in 2004 Ireland’s ratio of approximately 88 pharmacists per 100 000 people was, in fact, better than the EU15 average of 81 per 100 000 (WHO Regional Office for Europe, 2007). A further report (Indecon International Economic Consultants, 2003) concluded that removing the derogation would be a positive step towards helping to reduce the shortfall in pharmacists and improving access in rural areas.
The Pharmacy Review Group’s report, published in 2004, recommended opening up Ireland to further competition in the pharmacy sector, with the safeguard that no single entity should be able to have more than 8% of the community pharmacy contracts in any one of the former Health Board areas. Among the Review Group’s other recommendations were the separation of prescribing and dispensing premises, a performance review of pharmacies every five years and the removal of EU derogation once a new Pharmacy Act was introduced. The Review Group report met with a critical reaction from the Irish Pharmaceutical Union, which warned that the recommendations threatened the future of independent pharmacies and the availability of medicines in some parts of the country (IPU 2004). In June 2005 the MoHC announced that the Government had approved new pharmacy legislation intended to increase competition and raise standards in the pharmacy sector. Most of the recommendations of the Pharmacy Review Group had been accepted, with the exception of restricting the number of pharmacy contracts that may be granted to a single entity operating in any area (DoHC, 2005c).
The Pharmacy Act of 2007 represented the first complete overhaul of the regulation of pharmacy in Ireland in 130 years (Pharmaceutical Society of Ireland, 2007). It removed the EU derogation, which will also apply to pharmacists from non-EU/EEA countries, subject to a language test. The Act also introduced, for the first time, fitness-to-practise provisions, to ensure the highest standards are met by pharmacists and to safeguard the safe and effective delivery of pharmaceutical services to all citizens. These provisions fall under the auspices of a new independent Pharmaceutical Society of Ireland.
A total of 1414 dentists and 552 optometrists had contracts with the HSE to provide services under the GMS scheme at the end of December 2006 (HSE, 2007g) (see Table5.8). There are approximately 700 optometrists registered with the Association of Optometrists Ireland (Association of Optometrists Ireland, 2007).
Dentists are required to complete five years of dental school training before beginning practice. Both Trinity College Dublin and University College Cork offer courses in dentistry, although many students travel to the United Kingdom. The first two years of the course are spent on the university campus studying basic medical science. The last three years are spent in the Dental School and Hospital. The majority of dental graduates enter general practice, providing a complete service to patients in diagnosing, treating and preventing oral and dental disease, correcting irregularities and replacing missing teeth. A large proportion of graduates enter the public dental service which provides care for medically entitled patients and children through the public health clinics operated by the HSE. A small number of graduates will find opportunities in the dental hospitals as house officers or registrars, perhaps with postgraduate qualifications leading to consultant positions.
5.2.2 Planning for health care personnel
Improved workforce planning
The need for improved workforce planning was signalled in the National Health Strategy and action has commenced on strengthening this function within the HSE and the DoHC. This has been supported by research undertaken by the Irish National Training and Employment Authority (FÁS) into the labour market in health care, which identifies current and future shortages of health care skills up to 2015 (Foras Áiseanna Saothair, 2005). A joint committee on workforce planning was established in 2006 with representatives of the DoHC, DoF and Department of Education and Science, as well as the HSE. The group’s initial task is to review future human resource requirements in disability, care of older people and cancer services. The FÁS is also undertaking a more detailed analysis of a smaller number of professions due for completion in 2008. Health sector analysis has now been included in the work programme of the Expert Group on Future Skill Needs, reflecting the importance of the health sector in the national economy. Work has also commenced on a national workforce planning strategy in conjunction with the HSE.
One key issue has been the European Working Time Directive (EWTD). The EWTD requires that, from 1 August 2004, both consultants and NCHDs work for not more than an average of 58 hours per week on a hospital site. Furthermore, these doctors can no longer be required to work for more than 13 hours per day on site, and certain other rules regarding minimum rest and break periods must be put in place. By 1 August 2007 the number of hours worked should be no more than an average of 56 hours per week on site. This limit must reduce to an average of 48 hours by 1 August 2009. The EWTD does not apply to self-employed individuals, including GPs.
The need for Ireland to fully comply with the EWTD for NCHDs and to implement appropriate hospital planning, as well as medical training and education measures, led to the establishment of the National Task Force on Medical Staffing under the chairmanship of management consultant David Hanly in 2002 (Hanly, 2003). (See Chapter 6 Provision of services for further details).
Subsequent to this report, a number of initiatives have been put in place, as described here.
- A national coordinator and support team have been appointed, draft rosters and hours recording systems developed, and extensive work undertaken by health agencies at local level.
- Training principles and advice on safe, EWTD-compliant, rosters have been provided to employers by the postgraduate medical training bodies and the Medical Council.
- The National EWTD Implementation Group (NIG) has been established to give guidance to Local Implementation Groups (LIGs) and to oversee pilot projects.
Full implementation is dependent on industrial relations agreement. Discussions under the auspices of the Labour Relations Commission are ongoing at the time of writing.
It is still too early to judge the impact of the National Health Strategy and the recommendations of the Task Force on Medical Staffing. This latter report estimated that there should be 2200 NCHDs in training in Irish hospitals – a decrease of 44% compared to current levels – while the number of consultant posts should ultimately be increased to 3600 posts. Overall, this would increase the number of doctors working in the acute health system by 125. In order to meet these targets, 767 undergraduates in medicine would be required annually for several years. However, meeting this target may prove problematic without significant additional investment, given that at the time of writing, only approximately 300 home and other EU nationals are training in medicine in Irish universities. The majority of non-EU nationals still leave the country upon completion of their training and many Irish graduates are also going abroad because of problems in career structures in the Irish system. The increasing feminization of the workforce may also mean that more flexible working hours and job-sharing arrangements may be necessary, which, again, may increase the overall number of doctors required. Moreover, since 2007, entry to medicine has been a graduate-only system and the impact that this will have on the number of doctors is yet to be determined. The new system will mean that the time required to become a doctor may be even longer, deterring some individuals, and there are also concerns about the need to change methods of teaching and training to deal with a more mature group of graduates. It will take some time to see what effect the changes recommended in the Fottrell and Buttimer reports (Postgraduate Medical Education and Training Group, 2006; Working Group on Undergraduate Medical Education and Training, 2006) (see later) will ultimately make both to the number of students training and the ability of the system to retain the workforce.
Psychiatric nurses and skill mix
One key area of the workforce in which changes in staffing and skill mix are required is mental health care. The Government’s report on the strategy for mental health, A Vision for Change, places great emphasis on moving towards much greater provision of community-based rather than hospital-based services. The supply of psychiatric nurses and other mental health professionals is important for the effective implementation of this concept.
Although the number of individuals entering psychiatric nurse training have increased from 83 in 1998 to 343 in 2007, according to the strategy report, A Vision for Change, this is sufficient only to allow a limited scope for future development in the field of mental health care, treatment and prevention. Moreover, it does not accommodate the identified needs for the development of Primary Care Teams and child and adolescent mental health (CAMH) services (Expert Group on Mental Health Policy, 2006). A total of 90% of psychiatric nurses remain hospital based, and there is an unequal distribution of nursing staff across the country. In some areas, where there are staff shortages and an overreliance on overtime and agency staff, the focus on care tends to be on providing a safe service, rather than on delivering high-quality patient contact and providing therapeutic relationships. The psychiatric nursing staffing needs identified in A Vision for Change suggest the potential for a reduction in the number of psychiatric nurses needed in the new mental health service and an increase in a range of multidisciplinary personnel in order to provide a comprehensive mental health service. The report A Vision for Change estimated a total staffing requirement of 10 657, that is, a net increase of 1800 posts. This, however, requires the reallocation and remodelling of existing resources, along with extra funding and personnel. An audit of resources is under way in the HSE at the time of writing (Independent Monitoring Group, 2007).
Changes in skill mix and skill utilization, as envisaged, should facilitate increased use of health care assistants to support the delivery of nursing care through the freeing up of psychiatric nurses to focus on therapeutic care interventions. A steering group to oversee the mainstreaming of Health Care Assistant posts in the mental health service has been established (Department of the Taoiseach, 2006). One of the principles underpinning the introduction of health care assistants in mental health services is to facilitate the development of higher level nursing input into patient care by allowing the nurse to divest her/himself of certain duties without impinging on patient care.
The report A Vision for Change also identified the requirement for a multi-professional personnel plan to be put in place, linked to projected service plans. This will examine the skill mix of teams, how staff are deployed between teams, and the geographical location of the teams. The personnel plan will be developed by the National Mental Health Service Directorate, working closely with the HSE, the DoHC and service providers (Independent Monitoring Group, 2007) and should facilitate increased skill mix and teamwork across mental health services in future years.
Supply of general practitioners
According to the ICGP, at the time of writing, job opportunities in general practice – both full- and part-time – are plentiful. GMS scheme lists may become available, and are advertised through open competition; however, there may be less competition for lists serving rural areas. Another route into general practice is to apply for an assistantship at an existing GMS practice, with a view to becoming a partner. Assistants cannot become partners or take patients from a list for at least six months, and entering a practice does not guarantee a practice partnership.
There are some restrictions placed on GPs who participate in the GMS scheme. Since 1995 all GPs in the GMS scheme need to have “Certification of Specific Training” (or Acquired Rights) in general medical practice issued under EU Directive 93/16 by the Medical Council of Ireland, and they also need to pass the entrance examination for membership of the ICGP. Applicants need to have a significant amount of experience in order to enter general practice. A points system is in operation, with points acquired for experience in secondary care or via general practice training schemes, research and publications, membership of professional bodies and other relevant qualifications. In contrast, GPs entering private practice only need to be registered with the Medical Council (see Subsection Training of health care personnel, within Section 5.2 Human resources).
A substantial number of GPs still work in single-handed practices. Reforms introduced in the mid-1990s put in place GP Support Units in each Health Board to provide advice and incentives to encourage GPs to participate in cooperative practices. Some have developed into Primary Care Units, consistent with the goal within the Primary Care Strategy of integrating GP services into a coordinated and holistic primary care service that has links with acute care services.
Another supply-related issue that has been raised as a concern in the past has been access to out-of-hours GP services. The Health Boards (and now the PCCC Directorate within the HSE), working in partnership with GPs, developed schemes to improve access to out-of-hours Primary Care Services. One such example can be seen in the former North Western Health Board region where the out-of-hours service established in Donegal had more than 32 904 contacts in 2002, with a target of 46 000 contacts in 2003. In 2003 the scheme was expanded into South Donegal, Leitrim and Sligo, while under the CAWT Initiative the Primary Care Sub-Group have explored options for cross-border out-of-hours arrangements with colleagues in Northern Ireland. By the end of 2004, 62% of all GMS patients had access to similar out-of-hours services provided by GP cooperatives, and in 2006 the Government provided funding to increase this to 70% or 2.75 million people.
General practitioner contract review
The ICGP, as the representative body for GPs, has in recent years called for more flexible working arrangements, claiming that the current GMS contract requires GPs to be available 24 hours per day, 7 days per week. Given the high proportion of female GPs, the Council has argued that these working hours may not be attractive, also claiming that, as a result, as many as 20% of students currently training in primary care will be reluctant to go into general practice. This, in turn, would make it more difficult to recruit the additional GPs needed for the Primary Care Strategy (Shanahan, 2003), especially in light of the ageing of the GP workforce in Ireland (see Chapter 6 Provision of services). Indirectly, the introduction of the EWTD may also have an impact. One concern is that GPs who are not subject to the EWTD may have to pick up some of the duties of NCHDs whose working hours are now restricted. However, the impact of the EWTD on general practice, if any, remains to be seen.
The Government has recognized the need for a new contract as part of primary care reform and included this as one of the objectives of the DoHC’s 2005–2007 3-year strategy (DoHC, 2005e). In October 2005 a review of the GMS contracts/scheme and all publicly funded primary care services involving GPs commenced under the auspices of the Labour Relations Commission. It was intended that this review would encompass the nature of service provision by GPs in relation to the achievement of defined population health objectives and the best possible person-centred services in line with the strategy “Primary Care: A New Direction”. Through this process the DoHC and the HSE are seeking to progress national policy, which is to develop comprehensive, multidisciplinary services in the primary care setting. The aim is also to further extend the nature of services beyond the traditional “diagnosis and treatment” model to encompass health promotion, disease prevention, management of chronic illness and to extend the hours of availability of primary care services.
On 19 December 2019, health minister Simon Harris and Minister for Finance, Public Expenditure and Reform Paschal Donohoe launched a new contract for consultants working in the Irish Health Service Executive [https://www.gov.ie/en/news/de8eb8-ministers-for-health-and-finance-public-expenditure-reform-announce-/].
In a departure from previous contract types which allowed for private work, from the second quarter of 2020 all consultant appointments under the new consultant contract will allow for work only in the public service. Private practice is no longer permitted for consultants employed by the State in keeping with the Sláintecare health reform programme and the goal of single-tier public hospital care. The decision is also supported by the findings of an Independent Review Group [https://www.gov.ie/en/publication/28ddfd-report-of-the-independent-review-group-established-to-examine-privat/] chaired which examined private activity in public hospitals and approaches to removie it.
The requirement to take up this new contract applies only to new appointments. Consultants already in post can choose to take up the new contract or remain on their current one. To make up for the potential loss of income, contracts will be offered between €222,460 and increasing to €252,150 by July 2022.
5.2.3 Training of health care personnel
In Ireland students must study medicine for six years20 at one of five medical schools: Trinity College Dublin, University College Dublin, University College Cork, National University of Ireland, Galway or the RCSI. From 2007 a new graduate entry stream has provided an additional 240 EU medical school places per annum on the basis of 60 per year over a 4-year period. The University of Limerick has also opened a new school of medicine which will accommodate half of the first cohort of graduate entrants to medicine.
At the time of writing, entry requirements for undergraduate courses are based on school leaving qualifications (the Leaving Certificate). However, from 2009 a new selection process for entry to undergraduate medicine will be introduced, comprising a combination of the Leaving Certificate and a medical schools admission test. This will be open to all students who achieve a threshold level of 480 points in their Leaving Certificate and meet matriculation requirements. Credit for Leaving Certificate performance will be moderated from 550 points onwards, with one point added for each five points scored in the Leaving Certificate results. This will mean the maximum points which can be added to the candidate’s overall score is 550. The medical school admission test will measure general and personal skills and abilities that are not directly assessed in academic examinations.
The first two or three years of the course are university based, concentrating on the core sciences of anatomy, biochemistry, physiology and cognitive sciences, while for the last three years students are based in university teaching hospitals where teaching is focused on clinical medicine and related subjects such as pathology, pharmacology and public health medicine.
In 2003, 831 students were admitted, compared with 736 in the year 2000, but the number of non-Irish EU students had decreased from 345 to 315, although this is still in excess of the quota of 305 places for EU students funded by the Higher Education Authority in 2003 (Box5.2). This quota was introduced in 1978 and in the view of the Medical Council needs urgent revision to take into account current personnel requirements (Medical Council of Ireland, 2004). A government initiative on medical education and training, announced in February 2006, will more than double the medical school places for EU students from 305 to 725 (this will be made up of a new graduate entry stream (240 places)), and will increase the number of EU undergraduate places to 485 on the basis of substituting 180 non-EU places. An additional 110 EU undergraduate places were provided between 2006 and 2007, and the first 60 graduate entry places were provided in 2007.
An earlier review of the medical schools conducted by the Medical Council in 2001 reported that from 1995 to 2000 there had been little change in the number of students admitted, the exceptions being University College Dublin and the RCSI, which are linked to Penang Medical College and the International Medical University in Kuala Lumpur. (These Malaysian students undertake the first two years of their medical training at University College Dublin and RCSI). The 2001 review also reported that, with the exception of the students at the RCSI, female EU students outnumbered male EU students by a ratio of two or three to one (Medical Council of Ireland, 2001). In 2003, non-EU students outnumbered EU students at all five medical schools.21
Students can receive an MB (Bachelor in Medicine), BCh (Bachelor in Surgery) or BAO (Bachelor in the Art of Obstetrics). Graduates are then entitled to work in Irish hospitals and recognized hospitals elsewhere to complete a 12-month internship, usually consisting of six months in medicine and six months in surgery, during which time they are provisionally registered with the Medical Council. Following successful completion of this internship, indicated by a Certificate of Experience issued by the Dean of their medical school, doctors are entitled to proceed to full registration with the Medical Council.
All doctors who wish to practise in the Republic of Ireland should be registered with the Medical Council. The Council maintains two registers, the General Register of Medical Practitioners and the Register of Medical Specialists. There are three types of registration within the Registers which contained over 17 000 names in July 2005. Full registration allows fully independent practice in any setting; internship registration allows a doctor to undertake internship training for one year under consultant supervision; and temporary registration allows non-EU doctors to be employed and receive further training (Medical Council of Ireland, 2003). Following registration, doctors may continue with further specialist postgraduate training which can last between three and seven years for disciplines such as surgery or general practice, or graduates may seek to work in academic medicine or hospital management.
Undergraduate student fees are covered by the Department of Education and Science under the “Free Fees Initiative”, a scheme that is not means-tested and applies to all EU national students (or those granted refugee status) ordinarily resident in an EU country for three of the previous five years, who are undertaking a first undergraduate degree. Means-tested grant schemes (for living expenses) are also in operation, which include special top-up payments to disadvantaged students. Institutions also receive block grants for courses from the Department of Education and Science and are heavily dependent on generating additional income from non-EU students, who will pay fees of €29 000 per annum in 2008–2009. By contrast, undergraduate fees for medicine were approximately €7500 per annum in 2007–2008. Earlier research indicated that for home and EU students, 58% of income was derived from the free fees scheme, with the remainder coming from block grants (Department of Education and Science, 2003).
A review by the Medical Council criticized the quality of medical education in Ireland, commenting that in a rapidly changing environment, governed by international standards, Irish medical schools were struggling to meet the necessary medical education benchmarks but were still managing to produce competent graduates due to the efforts of medical school staff (Medical Council of Ireland, 2004). In light of these comments, in 2003 the Medical Council formally adopted plans to introduce accreditation for medical education courses, using internationally recognized standards, that is, World Federation of Medical Education benchmarks. Furthermore, following the Medical Council’s review, the DoHC and the Department of Education and Science agreed to set up a working group under the chairmanship of Professor Patrick Fottrell to look at the future of medical education (Working Group on Undergraduate Medical Education and Training, 2006). The Fottrell Report published its conclusions in 2006. Among its recommendations were a call to increase the number of EU places in undergraduate medical education, modernization of the course curriculum in the medical schools, the introduction of graduate entry programmes and an increase in the number of academic clinicians in post. The Government responded to the conclusions of the review rapidly in 2006 (see later).
Medical postgraduates wishing to become GPs needed to undertake one of the ICGP-approved General Practitioner Specialist Training Schemes lasting four years at one of 12 centres across the country. Approximately 150 places are available annually, with courses consisting of two years in hospital training and two years in general practice (part of which may be overseas for certain centres). However, a survey indicated that among the crop of 2003 interns, only 15% of respondents wished to pursue a career in general practice (Finucane, 2004). This would suggest that fewer interns are interested in general practice than the current number of training places available. Many students have undergone postgraduate training in the United Kingdom, but since July 2002 only full 3-year (United Kingdom) general practice programmes are accepted by the ICGP. Self-structured hospital training (which precedes a 1-year general practice training programme) is no longer recognized for GP training purposes in Ireland.
The Primary Care Steering Group, which reviewed the implementation of the 2001 Primary Care Strategy, has called for the establishment of a national group to examine and make recommendations on GP education, training and personnel needs in order to meet future requirements. The Steering Group found a wide variation in postgraduate and undergraduate primary care training, and was not able to identify the current level of investment in education and training by the Health Boards/HSE. These findings are consistent with those of the Medical Council Review of Medical Schools which concluded that “general practice remains a minor part of the curriculum” (Medical Council of Ireland, 2004). The recommendations included having a common module for primary care training and (again, in common with the National Task Force on Medical Staffing) to establish a National Health Service Training and Development Authority to coordinate and target training and development in the health services in general (National Primary Care Steering Group, 2004).
The number of nurses who have trained outside Ireland, particularly non-EU nationals, has become significant in recent years. By 2006 more than two thirds of all new qualification registrations were from individuals who had trained in other EU and non-EU countries (see Table5.14). The majority of newly registered general nursing qualifications were obtained outside Ireland, while the vast majority of specialist nursing qualifications were obtained in Ireland. At the same time, the number of Irish-trained nurses wishing to work outside the country continues to be high. In 2006, 576 Irish nurses and 301 non-Irish nurses sought one or more verifications (confirmation of nursing credentials) in order to work abroad (see Table5.15). Australia is the destination of choice for Irish-trained nurses and the majority return to Ireland within a relatively short period. The majority of nurses not trained in Ireland seeking verification are working temporarily in the country, and typically wish to move on to positions in the United Kingdom or the United States. In 2006, 116 nurses from India and 91 from the Philippines sought verification. The number of new students commencing nursing studies has also steadily increased (Table5.16).
Postgraduate medical training
The system of postgraduate training in Ireland has also been the subject of some criticism. It was argued that the time taken to complete training by NCHDs can vary by a number of years, depending on the number of patients that they are expected to treat within their facilities, and that there was also less time available for training and practice because of the increased administration and management demands (Kellet, 1999).
A survey of all interns conducted by the Medical Council in 2003 looked at their attitudes towards postgraduate training and long-term career plans. Of the 300 respondents, 165 (55%) were female, 221 were Irish citizens, 12 were other EU nationals and 65 non-EU nationals. According to the survey, 57% “strongly agreed” and a further 36% “agreed” with the statement: “It is likely that I will leave Ireland at some stage to pursue further training”. These percentages did not change when non-EU nationals were excluded from the analysis. Overall, 24% strongly agreed and a further 39% agreed that “postgraduate training is not as good in Ireland as in other countries”. Again, these percentages were not altered by the exclusion of non-EU nationals from the analysis (Finucane, 2004). The report’s author went on to conclude that:
... it is clear that all of the training bodies have to work to do better in making postgraduate training more attractive to Irish graduates. The stakes appear to be highest for general practice and some of the smaller specialties who may be facing future manpower shortages. A greater exposure to these disciplines is required, particularly at undergraduate level, before career plans are shaped.
The Report by the Forum on Medical Manpower (Forum on Medical Manpower, 2001) also highlighted the need for more fully trained doctors, with enhanced postgraduate training arrangements, and perhaps, most importantly, for more and earlier opportunities for fully trained doctors to take on responsibility in line with their experience. Further, the Report advocated an increase in the number of fully trained doctors and noted that the current balance between fully trained and partially trained doctors is not beneficial to optimal patient care, and for some doctors can result in heavy workloads.
While doctors in training can play a role in service delivery commensurate with their level of skill and experience, the primary responsibility of trained doctors is providing appropriate patient care. Career structures in Ireland may compound this issue, with the Forum on Medical Manpower noting that:
... the vast majority of consultants (80%) are aged 40 or over, while most NCHDs are in their mid-to-late twenties or early thirties. Consequently, there are relatively few fully trained hospital doctors in Ireland in their thirties – normally a highly productive age cohort. In many cases, this vital cohort is missing and working abroad with little immediate prospect of returning to a consultant post in Ireland. This phenomenon is set to increase as the shorter, more structured continuum of training develops, unless corrective measures are taken.
The Report of the National Task Force on Medical Manpower, chaired by David Hanly, made a number of recommendations with regard to postgraduate medical training. These reflect several limitations, including: the fragmented, overlapping and complex structure of existing training arrangements; the lack of regulation of the number of training posts at senior house officer and registrar grades which has allowed the number of NCHDs to grow; the priority given to service requirements over training needs; and the lack of involvement of any of the medical schools in postgraduate training (Hanly, 2003).
The Task Force recommended the establishment of a central, independent, statutory postgraduate training authority which would have some responsibility over the number of NCHDs by having to give explicit approval for, and stipulate the length of, training posts; have strategic responsibility for the development of medical education; and evaluate and monitor the quality of medical education and training. Other recommendations of the Task Force included stronger mentoring of NCHDs to help facilitate career progression; ensuring that time for training is protected within the terms of the EWTD; and including training in skills such as clinical governance, management, multidisciplinary skills, teamwork, communication skills and ICT in both undergraduate and postgraduate courses. Furthermore, all NCHD posts should become training posts. The Task Force also stated its belief that there is a future role for the medical schools to play in postgraduate training.
The Government commissioned an expert Postgraduate Medical Education and Training Group, under the chairmanship of Dr Jane Buttimer, to look at how to improve postgraduate training for NCHDs within the eventual maximum 48-hour working week. Another key area investigated by the Group was improving graduate retention (Postgraduate Medical Education and Training Group, 2006). Its report was published early in 2006 and among the recommendations set out were the introduction of a robust governance structure to drive forward reforms; independent expert evaluation of the training value of NCHD posts; development of financial/information systems and ICT infrastructure to generate an evidence base to underpin and support implementation of the recommendations; graduate retention measures, including the implementation of the National Flexible Training Strategy; and an increase in consultant numbers. The Training Group also called for systematic annual workforce planning exercises to identify the appropriate numbers required at various levels of training in each specialty and subspecialty, based on the staffing needs of the health service; and for the implementation of training principles to be incorporated into new working arrangements for doctors in training.
Reform of medical training and continuing education in Ireland
Welcoming both the Buttimer and Fottrell reports (Working Group on Undergraduate Medical Education and Training, 2006; Postgraduate Medical Education and Training Group, 2006), in 2006 the Government announced details of a €200 million initiative for major reform of medical education and training from undergraduate level through to postgraduate specialist training (DoHC, 2006d). As well as doubling the number of medical places for Irish and EU students over a 4-year period from 305 to 725, a new graduate entry programme for medicine was introduced in 2007. The curriculum and clinical training are being modernized to strengthen quality and in 2006, eight new academic clinician posts were created, jointly funded by the education and health sectors.
At postgraduate level, measures are to be taken to improve the retention of graduates from Irish medical schools through a range of approaches to enhancing the quality and attractiveness of postgraduate specialist training. NCHD posts with limited training value will be phased out and there will be better workforce planning to align the numbers of doctors in training with projected consultant vacancies. New training principles are to be incorporated into new working arrangements for doctors in training, and research in the health sector will also be enhanced.
The HSE allocation for medical education and training in 2007 was €16.1 million (€6.5 million revenue and €9.6 million capital). The HSE revenue funding includes additional funding totalling €3.3 million in 2007 to support the development of further initiatives, including:
- the appointment of additional academic clinicians;
- subsidized training abroad in specialties for which there is a shortage in Ireland; and
- research scholarships to promote research in medicine.