providing quality, safe and comprehensive anaesthesia services in ireland

40 Pages·2014·4.82 MB·English

Providing Quality, Safe and
ComPrehenSive anaeStheSia
ServiCeS in ireland
– a review of Manpower Challenges
NatioNal
CliNiCal
Programme iN
aNaesthesia
EndorsEd by nCPA, JFICMI & thE FACulty oF PAIn MEdICInE

01
foreword
T
he College of Anaesthetists of Ireland (CAI) and the national Clinical
Programme in Anaesthesia (nCPA) has been asked by the health service
Executive to review manpower planning for our profession. this report
represents the collective view of the College of Anaesthetists of Ireland, the national
Clinical Programme for Anaesthesia, the Joint Faculty of Intensive Care Medicine of
Ireland and the Pain Faculty of CAI.
the report has identified immediate challenges in provision of anaesthesia services.
these include an overdependence on international medical graduates and non-
training nChds, insufficient numbers of consultants and an inability to retain
newly trained consultants due to changes in working conditions and contracts. the
workforce in anaesthesia appears to have evolved rather than been centrally planned.
the hanly report 2003 did identify solutions, principally reconfiguration of acute
hospitals coupled with increased consultant numbers and decreased nChds, but this
has not been implemented.
In this report we have reiterated previously published standards for provision of
intensive care medicine and obstetric anaesthesia and we have published new
standards for service provision of anaesthesia. All of these standards are designed
to provide patients with the safest possible service. the temptation to maintain
workload despite a reduction in workforce will result in an erosion of these standards
and is not in the interests of patient safety. If the current situation is not rectified, in
a planned manner, we will see a reduction in service provision, which will impact on
other services and specialties.
this report provides the tools to identify the correct workforce for services and hospitals.
Its implementation is beyond the powers of its authors but we are prepared to work with
the hsE/dohC to do so. the ultimate aim of all parties is to provide safe effective care to
patients whether it is anaesthesia, intensive care medicine or pain medicine.
Dr David Mannion,
Chairman of working group
CollEgE oF AnAEsthEtIsts oF IrElAnd 1
working grouP
Dr David Mannion,
College of anaesthetists of ireland,
Chairman of working group.
Dr ellen o’sullivan,
president,
College of anaesthetists of ireland
Mr fintan foy,
Chief executive officer,
College of anaesthetists of ireland
Ms Maria golden,
Training officer,
College of anaesthetists of ireland
Dr Bairbre golden,
Director,
national Clinical programme of anaesthesia
Dr Jeremy smith,
national Clinical programme of anaesthesia
Dr James shannon,
national Clinical programme of anaesthesia
2 CollEgE oF AnAEsthEtIsts oF IrElAnd
table of ContentS
01: foreworD .....................................01 09: hanly / european working
TiMe DireCTive ............................21
02: exeCuTive suMMary ..............04
10: aTTriTion raTe ..........................22
03: inTroDuCTion ...........................06
11: flexiBle working .....................23
04: CurrenT sTaTus ......................08
- 4.1 Consultants .............................08 12: serviCe Delivery of
- 4.2 Trainees ..................................09 non Training posTs ................24
- 4.3 Non-training NCHDs .............09 - 12.1 Who Should Provide
- 4.4 Total Anaesthesia Anaesthesia? ...........................24
Practitioners in Ireland .........10 - 12.2 Career Grade NCHD? ............24
- 12.3 Level 5 Assessment ..............24
- 12.4 Trainee Numbers ...................25
05: fuTure planning in - 12.5 ICU NCHD Cover ....................26
anaesThesia Challenges ...12 - 12.6 Reduce Sites
Requiring 24/7 Cover ...........26
- 12.7 Consultants on Call ................26
06: nuMBers of ConsulTanTs
- 12.7 Summary .................................27
requireD in nexT 10 years ..13
- 6.1 Adult Critical Care ...................13
- 6.2 Adult Critical Care Retrieval ..13 13: naTional self suffiCienCy ..28
- 6.3 Paediatric Critical Care .........14
- 6.4 Pain Medicine ..........................14
- 6.5 Anaesthesia .............................14 14: working lifespan....................29
07: sTanDarDs ..................................16 15: privaTe ConsulTanTs .............29
- 7.1 Rosters ........................................16
- 7.2 Multiple sites ............................16
- 7.3 Work Scheduling ......................16 16: whaT nuMBers of Trainees
- 7.4 Emergency Theatre .................16 are requireD .............................30
- 7.5 Insufficient Manpower ............17
- 7.6 Services Requiring
17: ConClusion .................................32
24/7 Cover ................................17
appenDix 1. CriTeria for approval
08: reConfiguraTion .....................19
of hospiTals for speCialisT
- 8.1 Hub and Spoke .........................19
anaesThesia Training posTs ......34
- 8.2 24/7 Cover in
Every Hospital? ......................20
BiBliography ..................................36
CollEgE oF AnAEsthEtIsts oF IrElAnd 3
02
exeCutive Summary
 Anaesthesia manpower in Ireland was recommended 10 years ago. In
comprises Anaesthetists, Intensive intensive care medicine, the ratio of
Care Medicine specialists (intensivists) consultants appointed is much lower than
and Pain Medicine specialists. there is the recommended level e.g. in paediatric
frequent overlap between anaesthetists intensive care medicine it is 20%.
and the other two specialties i.e.
anaesthetists may work on a part time  the CAI/nCPA recommend that only
basis in one or other of the other two anaesthetists who are on or eligible for,
specialties. the Anaesthesia specialist register of
the Irish Medical Council (IMC) should
 70% of the workforce is made up of be independently providing anaesthesia
consultants (45%) and College of to Irish patients.
Anaesthetists trainees (25%). the
other 30% of the workforce is made  Anaesthetic services should adhere
up of non-training nChds. this latter to the standards laid down by
group is a declining workforce, who professional bodies including the CAI,
are usually employed on six-monthly the Association of Anaesthetists of
contracts. the Irish health service is great britain & Ireland (AAgbI), Joint
overly dependent on this group to Faculty of Intensive Care Medicine
maintain existing anaesthesia services. in Ireland (JFICMI) and the Intensive
Care society of Ireland (ICsI). these
 International medical graduates (IMg) will include availability of anaesthetic
constitute 49.2% of the anaesthesia personnel and appropriate skilled
workforce. this indicates that to date, assistance to anaesthetic personnel.
the policies for recruitment, training
and most of all retention of Irish  t he CAI/nCPA recommend certain
graduates have been inadequate to new minimum standards in terms of
meet the needs of the Irish health anaesthesia provision and running of
service. theatre schedules. this is being done to
prevent the erosion in standards, which
 A number of studies have provided may occur due to insufficient manpower,
indicative numbers of how many at present. In addition, it will allow planners
anaesthetists and intensivists are estimate what personnel are required for
required to deliver anaesthesia delivery of services in anaesthesia, ICM
services in Ireland. At the time of the and pain medicine.
first of these, hanly 2003, the ratio of
consultant anaesthetists per 100,000  t he number of hospitals and services
population was 8/100,000. this report requiring 24/7 anaesthesia services
recommended increasing to 11/100,000. should be reduced through centralisation
the current ratio of anaesthesia of services particularly intensive care
specialists is 8.8/100,000 and the medicine and obstetric services. In doing so
number of consultants is 74% of what this may have the dual effect of reducing
4 CollEgE oF AnAEsthEtIsts oF IrElAnd
anaesthesia manpower demand and also would opt to stay in Ireland, when trained.
ensuring, where services are centralised, neither is the case at present. there
that current professional standards are is scope to facilitate increased training
adhered to. the report ‘The establishment numbers up to 40 per year. this would
of hospital groups as a Transition facilitate achieving 11/100,000 much more
to independent hospital Trusts’ will quickly. however without a commitment to
establish a framework within which such increase consultants, there should be no
reorganisation may occur. increase in training numbers.
 t he Irish health service needs to recruit
many more consultant anaesthetists,
intensivists and pain medicine specialists
in the near future, if there is not to be an
inevitable reduction in hospital activity
caused by a lack of anaesthesia services.
 C onsultant recruitment has become
problematic following the 2008 contract
restrictions and the introduction of
reduced pay structures for new entrants.
Anaesthetic and ICu consultant positions
are currently unable to be filled in a
number of hospitals because of this.
A recommendation document on
consultant recruitment and retention
has been produced by a joint hsE/Forum
of Postgraduate training bodies (FPtb)
group and this may provide the solution
to the issue. Whatever solution is agreed
needs to recognise the considerable
onerous duty which anaesthetists and
intensivists are required to provide to
maintain the smooth running of the
health service.
 W e are currently training sufficient
numbers (30 per annum) to staff our
health service with anaesthetists at a level
of 11/100,000 population. however this is
assuming we have reached steady state in
consultant numbers and that most College
of Anaesthetists of Ireland (CAI) trainees
CollEgE oF AnAEsthEtIsts oF IrElAnd 5
03
introduCtion
T
he Anaesthesia community in Ireland 6. to consider how Anaesthesia, Intensive
was asked the by the national Care Medicine (ICM) and Pain Medicine
Programme director for Medical may be developed to fit changes in
training, hsE, Prof Eilis Mcgovern, to Irish health service delivery.
“consider and crystallise their views on
workforce planning within their specialty”. Workforce planning is a difficult process
this request was channelled through the within the medical field because the
College of Anaesthetists of Ireland (CAI) variables are many. they include the model
and the national Clinical Programme of delivery of care, resources available for
in Anaesthesia (nCPA). over the past manpower recruitment, developments in
twelve months we have held a number of technology, etc. two previous reports exist
meetings on this topic including a session into Medical Manpower Planning in Ireland,
at the CAI strategy day 2012, a dedicated report of the national taskforce on
Manpower Planning Workshop in the CAI Medical staffing 2003 and A Quantitative
and the Winter Anaesthetic Meeting 2013. In tool for Workforce Planning in healthcare:
addition we have circulated two consultation Example simulations 2009.
documents to the entire anaesthesia
community and solicited responses to the first of these reports, hanly 2003,
it. this document reflects the views of focused on reducing nChd hours, in line
anaesthesia practitioners in Ireland. with the European Working time directive.
In doing so it also made recommendations
the iSSueS we were aSked to on increases in consultant manpower
foCuS on inCluded: to provide a consultant provided
1. to estimate an appropriate ratio of service, development of a centralised
anaesthetists per head of population? medical education and training office
and reorganisation of acute hospitals.
2. to consider how many additional In respect to the current task, it found
consultant anaesthetists we estimate will that Ireland currently had a career grade
be needed in the next 5 and 10 years? position in nChd employment, in practice
if not in name. It recommended that this
3. to directly link future training numbers should be phased out in a structured
to workforce projections. manner. It sought to reduce nChd numbers
by 44% and increase consultant numbers
4. to consider the service implications of by 108% so that the ratio of consultants to
positions held by non-training nChds. nChds went from 1:2.2 to 1:0.61.
5. to inform the hsE MEt what policy some aspects of the hanly report were
drivers will influence the future of implemented including establishment
anaesthesia in Ireland. of a central medical education and
training office.
6 CollEgE oF AnAEsthEtIsts oF IrElAnd
hanly reporT - nuMBer of DoCTors
5,000
4,922
4,000
3,944
3,600
3,750
2,500
2,200
1,731
1250
0
 2003  projection  2013
the key proposals in relation to changes the second report, which addressed
in consultant and nChd numbers were anaesthesia workforce, was by FAs and
not implemented as seen above. looked at consultant and trainee numbers
in anaesthesia under the conditions that
the ratio of consultant anaesthetists pertained in 2009 and under a projected
to nChds at the time of hanly was 1:1.2 scenario. the baseline scenario used
and it remains at that level today. the the ratio of consultant anaesthetists
essential recommendations of the hanly per 100,000 of population at that time,
report with regard to increasing the which was 8 and estimated consultant
number of consultants and reconfiguring and trainee requirement up to 2020. the
the delivery of acute hospital services number of trainees required to graduate
remain pertinent today. to Cst requirement per year was 14. the
projected scenario used the consultant
the 2003 hanly report also devised a manpower numbers that were predicted
formula to relate trainee numbers to necessary by the 2003 hanly report.
future consultant numbers and in this In this scenario anaesthesia consultant
document we use this to predict our numbers increased to 11 per 100,000 of the
training requirements. the variables population and the annual trainee output
that went into this formula included the required was 29. the FAs report did
target number of consultants, the average caution that its numbers were developed
working years of a consultant, the number on a macro scale (11/100,000) and it did
of years training, the likely number of not look at the micro level as to what may
future consultants who would opt for be required in different specialty areas or
flexible working hours and finally the geographic regions e.g. intensive care.
attrition rate between numbers of trainees
who achieve Completion of specialist
training (Cst) and those who eventually
go on to practice as a consultant in Ireland.
CollEgE oF AnAEsthEtIsts oF IrElAnd 7
04
Current StatuS
T
o begin the process of in practice, almost all practitioners are
workforce planning we first consultant anaesthetists who allocate a
determined what the current proportion of their sessions to delivering
numbers of consultants, trainees and acute and chronic pain programmes.
non-trainees were.
to look at workforce numbers we
4.1 ConSultantS therefore need to look at the numbers
the CAI train doctors to consultant level in each of these specialties. Many
to deliver anaesthesia in all specialties, intensivists and pain practitioners also
to deliver intensive care and to deliver practice anaesthesia and so will be
pain services. As such workforce planning included in anaesthetist numbers.
by the CAI must look at these three
different specialties. Anaesthesia is the hsE provided the College with their
recognised as a specialty by the Irish estimate of consultant numbers as of
Medical Council and the CAI is the only september 30th 2012 which were broken
Post graduate training body (Pgtb) down as follows:
that may train trainees to practice
anaesthesia in Ireland.
anaeStheSia
the Joint Faculty of Intensive Care anaesthesia 282
Medicine of Ireland (JFICMI), which is
intensive Care 23
a faculty of the CAI, royal College of
paediatric anaesthesia 23
Physicians of Ireland (rCPI) and the royal
College of surgeons in Ireland (rCsI),
pain Medicine 8
is the advisory body for intensive care
anaesthesia Total 336
training, accreditation and standards.
Although in theory graduates of any of intenSive Care
its parent colleges may pursue a career
intensive Care 4
in intensive care medicine, in practice the
vast majority of practitioners come from paediatric intensive Care 5
anaesthesia at present. Intensive Care
intensive Care Total 9
Medicine is currently seeking specialty
status recognition by the IMC.
the hsE estimate is sourced from
the Pain Faculty of the CAI regulates approved consultant positions. It is
the training and assessment of pain therefore not an accurate estimate of
specialists in Ireland. It also runs the actual consultants delivering service, as it
diploma and Fellowship in Pain Medicine does not take cognisance of whether the
for pain practitioners. A graduate of one post is filled or not, nor of locum posts.
of the other postgraduate training bodies
may seek a career in pain medicine but All practicing anaesthetists must be
8 CollEgE oF AnAEsthEtIsts oF IrElAnd