Shortage puts hospitals on critical list


What’s wrong with our approach in Ireland that we are running out of junior doctors? EITHNE DONNELLAN, Health Correspondent, tries to find out

IN THE past year there have been warnings from doctors all over the State that hospitals were in danger of having services curtailed or axed altogether as a result of junior doctor shortages across a range of specialities.

The Irish Association of Emergency Medicine predicted in April 2010 that a number of hospitals might have to close their emergency departments or limit their opening hours as a result of shortages. Two months later around-the-clock emergency services at Louth County Hospital in Dundalk came to an end, something which was due to happen eventually but not quite so soon.

A senior anaesthetist at Our Lady of Lourdes Hospital, Drogheda, Dr Michael Staunton, has also been warning for months about risks to patient safety as a result of the hospital’s inability to fill junior doctor posts in anaesthesia. At one point, it was so desperate that a junior doctor who was “unable to work on call because of extremely poor English” was taken on.

But what’s behind these shortages and who, if anyone, is responsible for them?

Some of those working on the frontline say the blame lies with the HSE, while others blame Government policy, the Medical Council, which regulates the medical profession, and a lack of opportunities for young doctors when they are finished their training in Ireland. There are those who say the fault lies with the young people now graduating from Irish medical schools who no longer want to work long hours in difficult conditions and are jetting off to countries offering better prospects.

Junior doctors traditionally rotate posts every six months – in January and July – as part of their training and that’s why talk of an impending crises over shortages peak at these times of the year.

In December, before the latest job rotations, the HSE said 165 junior doctor posts were vacant across the State. Nobody seems clear on how many jobs are now vacant following the latest rotations in the past week.

The very fact that hospitals themselves didn’t seem to know how many doctors they would be short until they saw who turned up for work on January 11th, following the latest rotations, is an indication of how ridiculous the current system is. What other business could be run in this way? Imagine a school re-opening after the summer break not knowing how many classes would be without teachers.

The reason for much of this lack of clarity is that a junior doctor might be offered a few different jobs and only at the last minute opt for one of them. In tandem with this, the HSE is still actively recruiting overseas and hoping to fill additional vacant posts in coming days and weeks, thus the number of vacancies remains fluid.

Historically, according to the HSE, about 55 per cent of the NCHDs (non consultant hospital doctors or junior doctors) in Ireland have been non-EU doctors. In addition to Irish junior doctors emigrating in increasing numbers in recent years, non-EU doctors are now finding Ireland a less attractive place to work for myriad reasons – cuts in pay and training grants, being offered dead-end jobs with little training in smaller hospitals, and few opportunities for career development.

The much-criticised Hanly report on hospital reorganisation in 2003 recommended the number of consultants in Irish hospitals be doubled from 1,731 to 3,600 over a decade. The Minister for Health, Mary Harney, has oft repeated that we need to halve our cohort of junior doctors – which currently stands at 4,650 – and double our complement of consultants.

While there has been some increase in consultant numbers – they stood at 2,434 in 2010 – the numbers of junior doctors in the system has also continued to increase – from 4,170 in 2005 to 4,650 last year.

Dr Mark Murphy, who is six years out of medical school and a GP trainee based in Sligo, argues we have far too many NCHDs, but the health service has evolved to become completely reliant on them to do jobs that could be done by other healthcare staff, such as finding and collecting radiology films, administering drugs, taking ECGs, inserting IV cannulas and taking bloods.

According to Dr Murphy, somebody needs to shake up the system, but he believes there is an inertia in the Department of Health about implementing expert reports such as Hanly. “Most nurses would prefer to take on extra roles but they are prevented from doing so.”

Doctors in the US can train to be consultants in emergency medicine within three years of leaving college, he adds, but here the training could take more than a decade.

“We endure longer training times than anywhere else in the world, moreover it’s not good training. Thus we carry out service jobs for anything from seven to 15 years, hopefully getting training in the interim before we must leave our shores to polish up our training abroad,” he says.

This has all left us with a “pseudo manpower crisis”, he says, as a result of a failure to employ an appropriate number of consultants by western healthcare standards. In 2006 in New Zealand, he worked on a team with six consultants and two NCHDs, but says many Irish consultants have four NCHDs working for them alone.

NCHDs are also expected to spend much of their working life carrying out tasks that in most other systems would be carried out by other healthcare professionals, while “an embarrassing underuse of IT has exacerbated further the cultural dependency on NCHDs”, and there has been a failure to employ sufficient numbers of GPs.

Dr Anthony O’Connor, a trainee in general internal medicine at Dublin’s Tallaght hospital, believes the attractiveness of the jobs on offer is a bigger put-off for many junior doctors than pay cuts, with not all posts offering training. More than 1,000 of the NCHD jobs on offer do not provide structured training, making them less attractive to young doctors.

“Thirty-six hour shifts are still the norm for me and most people, and that is difficult to reconcile with having any quality of life. I think people will put up with that for a while, but the real problem is there is a logjam at the end, with no consultant jobs,” he says.

“And the work is getting a lot more difficult than it used to be. People can be quite aggressive because they are waiting for scans, waiting for admission and waiting for beds . . . it’s often the junior doctors and the more junior nurses who have to bear the brunt of people’s anger,” he adds.

He believes there are enough doctors coming out of medical schools. “I think the difficulty for hospitals is getting them in the places they are most needed when they are most needed,” he says.

Dr Chris Luke, an emergency medicine consultant at Cork University Hospital, has suggested graduates from Irish medical schools should have to work here for a number of years to plug the current gaps, given how much the State has invested in their training.

Dr Luke says they are leaving for other countries because they are not prepared to work as hard as their predecessors. Jobs are particularly demanding in hospitals such as Limerick Regional and Our Lady of Lourdes Hospital in Drogheda as a result of the centralisation of services.

But Dr O’Connor says welding people to the system is not the answer. “There needs to be more carrot and less stick,” he suggests.

In an attempt to establish how many vacancies are now in the system, Dr John McInerney of the Irish Association of Emergency Medicine says all emergency medicine consultants will be surveyed this week, following the latest changeover. He believes pay cuts and working conditions here are significant factors in the NCHD shortages.

The HSE counters that the shortage is an international problem rather than an Irish one. “Over the last two years, health services in the United Kingdom, other EU states, Australia and New Zealand have, with Ireland, experienced problems sourcing NCHDs to staff acute hospital services,” it says.

Given the global shortage, Ireland needs to offer terms and conditions as good as other countries, which it will find difficult to do in the current climate. Instead of offering better terms, it is having to plug gaps with costly locums. A hospital can pay an agency up to €2,000 a day for a senior house officer, for example.

At present, about 3,600 of the NCHD jobs offer structured training and the HSE says this will have increased to 3,750 by July. It has also begun offering two-year rather than six-month contracts to junior doctors – but these are not training jobs – as well as providing funding to help with visas, Medical Council registration and initial accommodation costs for those willing to come here from overseas.

Dr Staunton, in several letters to the HSE in recent months, has castigated it for doing too little too late to solve the crisis. “I am extremely frustrated that HSE management has done little or nothing in the last six months to address the NCHD shortage,” he said in one letter on December 10th last. He also referred to the HSE only advertising some jobs on new terms very late in 2010 when it wanted applicants in post at the start of 2011.

The HSE argues it has been working for months on the problem. It says it established a project group in April 2010 to devise possible solutions, initiated an international recruitment process with 11 medical recruitment agencies albeit with limited results, offered longer periods of employment for non- training posts, and helped resolve visa issues for doctors travelling here from abroad.

The Medical Council has confirmed it received 61 applications for registration from graduates of non-EU medical schools since November 1st. Just one of these applicants has so far been granted registration.

Our Lady of Lourdes Hospital has, meanwhile, managed to recruit some NCHDs from Hungary and Romania in recent weeks, and data from the Medical Council shows 11 Romanian doctors and five Hungarian ones have been registered since November 1st.

But local efforts such as this, while successful for now, are unlikely to be enough in the longer term to deal with the nationwide shortages. The factors which underpin them will have to be tackled for once and for all. Otherwise, as Andrew Condon, general manager of the HSE’s office of the national director of human resources, put it in internal correspondence last September, “difficult decisions” regarding which services can be maintained in which hospitals will have to be made.