When is a consultant not a consultant? Quite often actually

Shortly before 9pm on Tuesday the Department of Health sent TDs and Senators a series of documents which set out answers to questions submitted in advance of an appearance by the Minister for Health, Simon Harris, before the Oireachtas health committee.

Towards the back of the documentation, two tables were included which, when put together, showed for the first time precisely how public hospitals – particularly outside the cities – are increasingly relying on doctors who are not on the Medical Council’s register of specialists to serve in consultant posts.

The tables showed, for example, in South Tipperary General Hospital almost one-third of all the consultant staff were not on the specialist register.

A total of 73 consultants in various hospitals across the country were not on the specialist register.

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It must be said that doctors not on the specialist register are fully qualified medical personnel. Some – and the extent is not known – may also have been appointed prior to March 2008 when specialist registration was not mandatory for employment as a consultant.

However inclusion on the specialist register signals that a doctor has completed higher training in a particular field of medicine.

Inclusion on the specialist register signals that a doctor has completed higher training in a particular field of medicine

And over the last year medical organisations and politicians have raised concerns about the number of doctors who are not on the specialist register who are currently employed as consultants – with some linking the phenomenon to the overall recruitment and retention crisis which has seen health authorities unable to fill about 400 consultant posts on a permanent basis.

The Irish Hospital Consultants’ Association has voiced serious concerns about an increasing number of temporary consultant posts being filled by doctors who are not on the specialist register. It said this practice “violates the most basic professional standards within the public health services”.

Quality and safety

“The practice of appointing doctors who are not on the specialist register to work as consultants in our health services must stop immediately. It is not acceptable that doctors who do not have the essential specialist training, skills and expertise are treating patients as consultants in our acute health services. This compromises and undermines the quality and safety of care that is provided to patients in our hospitals.”

On foot of revelations regarding consultants not being on the specialist register, the HSE established an internal group to ensure that any risks arising were “mitigated and eliminated to the maximum extent” .

Separately, the country’s largest health insurer, VHI, said it would not pay public hospitals for treatment provided to subscribers by consultants who did not have specialist qualifications in the area in which they were practising.

The HSE said that hospitals could, in some circumstances, pursue patients directly over their bill if the account was not settled by the insurer.

All of which left open the question as to whether patients should be told in advance that a consultant to whom they were being referred may not be a specialist in the particular area.

Last December, Simon Harris in an interview with The Irish Times said patients should be told by the HSE if consultants who were providing their care in public hospitals did not have specialist training or qualifications and were not on the register of specialists.

Patients should be told by the HSE if consultants who were providing their care in public hospitals did not have specialist training or qualifications

Fianna Fáil health spokesman Billy Kelleher subsequently asked how patients would be given this information.

The HSE said that in essence it would be up to local management in hospitals to come up with their own arrangements. However, as The Irish Times reported this week, it has been suggested that one option could be for such consultants to wear special identification.

‘Acting status’

“At all times during the period(s) of acting in consultants posts, it must be communicated to patients, clients, staff and any other person dealing with the specialist register/senior register acting that the specialist register/senior register is acting in a consultant position rather than a permanent post holder or a post holder holding specialist division registration. This may be done by way of, for example, their named badge indicating the doctor’s acting status.”

HSE director general Tony O’Brien told the Oireachtas health committee last week that in each location where a consultant was not on the specialist register, his or her individual clinical director was carrying out a review “to establish what issues arise to provide us with a full picture of what we do or do not need to do”.

“When the review is completed, the relevant action will be taken”, he said.

The HSE also indicated to Louise O’Reilly of Sinn Féin that it would adopt a two -track process depending on whether the doctor was appointed before or after March 2008.

For those appointed before specialist registration became mandatory, the HSE is to ask such doctors to apply to the Medical Council to be assessed for a transfer to the specialist register. The HSE will meet any costs involved.

For those employed after 2008, a risk-mitigation system is to be put in place for each doctor to include a risk assessment, proposed restrictions on practice (if any) and a supervision and monitoring process by the clinical director or his/her nominee (if necessary).

Each doctor will also be asked to apply to the Medical Council for assessment for eligibility for specialist registration with the cost being borne by the HSE.

HSE management also told public hospitals last July that they should ensure that specified-purpose rather than fixed-term contracts were used to engage non-permanent consultant staff “and that such specified-purpose contracts are not renewed in a way that would create a liability for award of a contract of indefinite duration”.

The HSE also said they should “identify an early contract end date for those temporary/locum doctors in your employment who do not hold the qualifications required for the post they occupy and ensure that employment is terminated at that point ”.