Stretched to the limit: The high cost of consultant shortages

The Covid-19 pandemic has drawn public and political attention to the Irish health system and the courageous work of health workers on the front line. Before the pandemic struck, reporters from The College View identified and examined some of the major pre-coronavirus challenges faced by the Irish healthcare system, including waiting lists for some chronic conditions, the dependence on locums (doctors in temporary positions) in short-staffed hospitals, and the difficulty some parts of the population – Travellers, the homeless – have in accessing healthcare. These stories present facts and context to understand the Irish health system have been stretched to its limit as it deals with the effects of Covid-19.

A leading Irish hospital spent more than €7.6 million on doctors in temporary positions in the past five years – highlighting the nationwide shortage in hospital consultants.

St Vincent’s University Hospital Dublin saw more than a 200 per cent increase in their spending on locum doctors from 2015 to 2019, according to the hospital’s internal expenditure figures released to The College View.

The figures show the hospital in 2015 spent €884,000 on locums, doctors who work in the place of a regular doctor when that doctor is absent, or when a hospital or practice is short-staffed. 

In 2016, the hospital spent €1,013,350, while in 2017 the figure was €1,202,077

In 2018, the hospital spent €1,867,103 on locums, while in 2019 the figure was more than €2.7 million.

Hospitals must rely on locums because there are currently 2,800 consultant posts in Ireland, and 20 per cent – about 500 posts — are permanently unfilled, according to Dr Sean Tierney, Dean of Professional Development & Practice RCSI.

Dr Sean Tierney says that the number of locum doctors being employed in hospitals results in a lack of continuity in patient care. 

He said: “Particularly, if you have short term locums, that means patients are seeing one person in outpatient for their pre-op, they come in and have an operation done by somebody else, and then they have their post-op done by another person, so patient-centred care, having a relationship with an individual, is completely gone.”

“It’s not to say you couldn’t meet different doctors, but they should be working in a team structure, otherwise it’s very destructive,” he added.

Dr Teirney says that continuity of care is particularly relevant in the field of gynaecology, where much of the care is elective meaning that an individual can choose to have, or not have, suggested treatment.

He said: “Having somebody that you can come and ask questions to, who has time to see you, that’s all disrupted. That patient relationship is what delivers the best quality of care.”

“It’s not to say you couldn’t meet different doctors, but they should be working in a team structure, otherwise it’s very destructive,” he added.

He also says that locum doctors filling senior consultant positions in hospitals leads to a lack of leadership in the field.

He said: “Clearly if locums are trained to the same specialist level they should be able to provide safe services, but they often aren’t used to the local processes in a hospital.”

“They’re not in a position to influence or lead change in a hospital. So you’re taking somebody who should have a leadership role, in terms of developing a department, and you’re putting them in a service provision role, and you don’t necessarily have any leadership.”

“If you’re not a permanent post, you can’t change things. You can’t recruit new members of staff or put in place new procedures,” he continued.

Increased Reliance on Locums

Increased expenditure on agency staff has become a trend in Irish hospitals in recent years, with the National Rehabilitation Hospital, Coombe Women and Infants Hospital,  the National Maternity Hospital and Mercy University Hospital, all increasing their expenditure on locum doctors between 2015 and 2018.

Mercy University Hospital had the second-highest increase in this kind of expenditure after St Vincent’s, with nearly €890,000 being spent in 2018, compared to €374,897 in 2015.

But excluding St Vincent’s Hospital Dublin, all of these hospitals reduced the money spent on locum staff in 2019. 

In 2008, the government agreed on a new contract, which would result in salaries of up to €240,000 for consultant doctors. However, before this could come to fruition, the Minister for Health at the time, Mary Harney announced that due to the economic crisis, the deal could not be completed.

As a result, hundreds of consultants took legal action. A deal costing around €2million was made.

Following this, a pay cut of 30 per cent was introduced for consultants appointed after 2012, meaning that those appointed after that time can earn up to €50,000 less than a colleague with longer tenure.

Currently, consultants in Ireland can earn between €150,000 and €200,000 a year in the public health care system.

Two-Tier Pay System

Doctors argue that this two-tier pay system has made Ireland an unattractive option for consultants and as a result, hundreds of posts are left unfilled.

Minister for Health Simon Harris described the two-tier system as “unfair,” and as having an “impact on recruitment and retention of highly-skilled doctors.”

While the HSE’s dependency on agency staff has been widely criticised by consultants, a consultant OBGYN who asked not to be named says that with the understaffing hospitals are experiencing, doctors are grateful for any help they can get.

She said: “We’ve all worked as locums at some stage and an extra pair of hands is just helpful.” 

Gabrielle Colleran, vice-president of the Irish Hospital Consultants Association and a consultant paediatric radiologist, says that there are 160 non-specialist consultants in Ireland.

These are people who are working and paid as consultants but do not meet the requirements needed to be called a specialist consultant, according to Dr Colleran.

Specialist doctors are entitled to practice independently.

Dr Colleran says that she is not only concerned with locum doctors filling consultant posts, but with the effect of empty posts on patient care, saying that it leads to overworked doctors.

She said: “When a colleague comes to me and says “there’s a child who needs this…will you squeeze in an extra?” the answer is always yes.”

Dr Colleran said: “The reality is when we’re exhausted, and we’re over-stretched and we’re tired, we could miss something subtle or something small, that in a year’s time when it’s looked at again, could be early cancer… could be an early infection that we missed.”

Sally Madden, Dara Browne, Anja Zauers & Megan Jones

Image Credit: Her.ie