Over-reliance on junior doctors one of the factors behind trolley crisis

Medical training and staffing is in a mess, with serious implications for patient safety

Non-training scheme doctors (NTSDs) are the workhorses of the health system, doing much of the basic work and unsocial shifts. Photograph: iStock

Non-training scheme doctors (NTSDs) are the workhorses of the health system, doing much of the basic work and unsocial shifts. Photograph: iStock

 

One of the many reasons behind the ongoing trolley crisis in our hospitals is the mess that is medical training and staffing in the Irish health service.

As we know, hundreds of consultant posts lie empty because they cannot be filled, while hundreds more are occupied by doctors who do not have the specialist qualifications for the role.

And, as a major new report from the HSE’s National Doctors Training and Planning working group shows, our health system is increasingly reliant on a cadre of junior doctors who are constantly being churned both between Irish hospitals and from Ireland to other countries, instead of being able to build up their experience and qualifications.

This dumbing-down of medical provision in hospitals has obvious safety implications for patients, as had been frequently pointed out by Mr Justice Peter Kelly in the High Court when cases of individual errant doctors came before him.

And yet, as with so many other glaring issues in health, there seems to be little appetite outside Mr Justice Kelly’s courtroom for taking radical action to improve matters. This report is itself the scion of a previous report on medical training and career structures, dating back to 2014. And even though the latest report has been ready for some time and has been approved by the HSE board, it has yet to be published.

What the report shows is Irish hospitals’ massive reliance on non-training scheme doctors (NTSDs), most of whom hail from outside the EU.

NTSDs – effectively, any doctor not training to become a consultant – are the workhorses of the health system, doing much of the basic work and unsocial shifts.

‘Turnover effect’

Because their options are limited here (Irish and other EU doctors are prioritised for access to training schemes), and because conditions are better for them elsewhere, we are seeing a massive “turnover effect” whereby NTSDs arrive, gain some experience and then leave, to be replaced by less-experienced colleagues.

The result is the recruitment of doctors of “uncertain” ability and limited experience, as the report phrases it.

But why, you might ask, would any hospital with vacant consultant posts fill their wards with junior locums? Part of the answer is that the recruitment of consultants is cumbersome and lengthy. You first have to make a business case, then get approval from the chief executive of the hospital or hospital group, then clearance from the relevant HSE directorate, then pass through several levels of application machinery within the civil service.

Not surprisingly, this had led to significant delays in the appointment of consultants. In contrast, junior doctors can be hired fairly easily, either directly or through an agency, notwithstanding the “clear defects” Mr Justice Kelly has identified in these processes.

Never mind that it will cost an average €3,315 a week to hire a registrar through an agency, compared to €1,973 directly, according to figures quoted in the report. The HSE spends about €1.1 million a day on agency staff, a figure that has remained stubbornly high in spite of repeated promises that it will be cut.

Particularly reliant

Smaller hospitals are particularly reliant on NTSDs, the report shows. In Ennis Hospital in Co Clare, for example, all six junior doctors belong to this category. In South Tipperary General Hospital in Clonmel and Cavan General Hospital, the figure is about 85 per cent.

Having to wait behind EU applicants for training places might be understandable, but it isn’t the only obstacle faced by these doctors. Intern experience is not recognised, except for six non-EU countries, and prior experience is generally not recognised either, unlike in the UK.

“I can’t get onto the Irish training scheme because I’m from —,” says one non-training scheme doctor interviewed for the report. “I became very frustrated watching NCHDs [non-consultant hospital doctors] that I had helped to train pass me by and made a decision to apply to the UK training scheme.”

The solutions are in the report, though they will cost money. We need more consultants to make clinical decisions in hospitals. We need more trainee places to fill these posts. We need to wean ourselves off our reliance on inexperienced young, often transient, doctors. Canada, for example, employs only consultants, GPs and trainees.