Eoin Kelleher | Contributing Writer
A recent article by Dr Anthony O’Connor in the Medical Independent discussing the poor working conditions of Ireland’s junior doctors has sparked renewed media interest. His piece stemmed from the recent tragic suicides of two young doctors, and how difficult working environments contribute to personal difficulties for young medics. This article will provide a broad overview of the many reasons behind this crisis in the Irish health service.
St James’ hospital in Dublin, home to the majority of Trinity’s medicine students. Photo: HSE
A well-trained and motivated medical staff is essential to a functioning health system. However, more doctors than ever before are leaving Ireland. In 2011, half of interns (those junior doctors who are one year post-graduation) left Ireland. The talk amongst medical students now is not so much if you plan to leave, but rather when and where you plan on going. A future in Ireland is – for many – not on the table anymore.
Poor morale among junior doctors has been a problem in the Irish health service for many years. There have been many studies and reports into the scale of the problem. The IMO (Irish Medical Organisation, the official trade union for doctors) Benchmark Survey in 2011 found that 32% of junior doctors would not choose medicine again if they had a choice. The Career Tracking Survey (CTS) which in 2005 surveyed Irish doctors who graduated in 1994 and 1999 had a similar response. In comparison, in 2012 a survey of graduates from 2006 in the UK found that less than 1% regretted their choice of profession. Why is this the case?
Dangerously long hours are the most important contributing factor. Junior doctors are expected to work continuous shifts in excess of 24 hours, in many cases up to 36 hours, with little sleep and no breaks. During this time they are expected to provide quality care to the patients who depend on them. This is in direct contravention of the European Working Time Directive (EWTD), which the HSE – by its own admission – has failed to adhere to. The EWTD mandates that healthcare workers cannot work more than 48 hours per week. It was introduced in 2004, and was to be fully implemented by 1st August, 2009. In 2011, only one-third of junior doctors were compliant with the EWTD according to the HSE itself. This is an unsafe situation for both staff and, importantly, the patients who depend on them. A large body of research shows that working conditions such as these directly contribute to medical error and harm to patients. Moreover, it is harmful to the health and well-being of staff, further demoralising them and driving them to find new, more humane, employment. This contributes to under-staffing which stretches the health system and places patients at even greater risk.
Although there are regular media reports on the levels of overtime pay earned by junior doctors (usually reported in terms of the overall bill for all doctors, and leaving out the hours worked in overtime), what is often omitted is that many are not paid at all for the dangerous levels of overtime that they work. Junior doctors face flagrant breaches of their contract by the Health Service Executive (HSE). Non-payment of unrostered overtime (hours worked beyond one’s allocated hours) has been widespread in recent years. The withholding of pay that they are legally entitled to and have worked for leaves doctors demoralised and undervalued by their employer.
However, there are issues beyond working hours and pay that are pushing many doctors to emigrate. Training and opportunities for career development in Ireland are seen as limited. We need to move towards a consultant-delivered health care system rather than the current consultant-led one. This requires an increased ratio of consultants to junior doctors, with consultants working in teams with junior doctors to provide care, in place of each consultant post being supported by a team of NCHDs. Despite many reports outlining the need for this change (Tierney Report 1993, Hanly Report 2003, and Buttimer Report 2008), there has been effectively no progress on this, and many doctors remain in registrar posts even once they have completed their training, and so they are unable to put their hard-earned training into use.
What is more, a majority of junior doctors in Ireland rate the training they receive as poor in quality, structure, and organisation. Training is perceived to be of poorer quality here than in other countries to which Irish medical graduates can easily emigrate. Moreover, the importance of training is not emphasised or recognised by the HSE. In recent years, training allowances and grants have been cut.
Today, Ireland has to compete for doctors with other countries such as the UK, Australia, Canada and the US. These countries have better levels of pay, working conditions, training and quality of life compared to Ireland. And it is for these reasons that Irish junior doctors are moving there in their droves. Up until now, Ireland made up for the shortfall in junior doctors by actively recruiting doctors from abroad, often from developing countries such as India, Pakistan and Sudan. Doctors from these countries make up half of the junior doctor workforce in Irish hospitals. However, the majority of these foreign doctors languish in non-training posts under the same working conditions that drive our own graduates to leave. Unsurprisingly, Ireland is now finding it hard to attract foreign doctors to work here, and the shortage is becoming more acute.
There is no easy fix to this crisis. It requires a culture change in Irish medicine. The role of junior doctors must no longer be seen as primarily a service-provision role to carry out tasks over long shifts in a hospital. This system places patients’ lives at risk; overtired, poorly motivated staff are more prone to make mistakes, and are less likely to receive high quality training. Poor working conditions will fail to attract the best staff who are drawn to better health services abroad. Ultimately, care for all of us suffers. Instead, what ultimately must happen is that the role of a junior doctor is seen as a training post where young doctors spend time learning and training to practice medicine as part of teams of consultants. This is not a revolutionary idea, it has been advocated before, notably in the Buttimer Report (2008).
Just because current conditions have become the norm is no reason the situation cannot and should not change. Countries such as Australia, New Zealand and UK manage to provide an attractive work environment for staff at a reasonable cost to the health system. Medical graduates and junior doctors are the future of Irish healthcare, and without investing to retain them, train them and motivate them, the system will fail to serve those who need it, the public.
We should all, patients and staff, expect better from our health service. Would you board a flight piloted by a sleep-deprived pilot? Would you have a tooth pulled by a dentist who is falling asleep over her drill? You wouldn’t accept such poor treatment. And nor should you accept medical care from a doctor who hasn’t slept or sat down in over a day. You deserve better.
