Much is riding on the positions being adopted by Irish hospital consultants towards the new contract being offered by the HSE. The latest challenge for the Government is the apparent rejection of them in a recent survey of doctors.
The contract could be an important step towards retaining and regaining the Irish doctors who are lost to emigration. However, on its own, it will do little to address the worsening crisis in the medical workforce and the wider reasons why many trainee doctors won’t stay in Ireland and why many will not return to take up consultant positions, once fully trained.
The contract will not extract the State from its long-standing predicament, which is the so far unbridged gap between where we are now and getting to a place where there are far more consultant posts established and filled and sufficient numbers of other essential staff in place in Irish hospitals. That is what would make Ireland a much more attractive place for doctors to undertake speciality training and a place where they would want to make their future careers.
Instead, many trainees and some consultants choose to emigrate to countries such as Australia, where hospital consultants work in clinical teams with higher ratios of trainees, nurses and other essential staff, where they are responsible for fewer patients, meaning less need to triage patient wellbeing and where they have a work-life balance that is conducive to reaching retirement age in reasonable health, than they would have if they stayed or returned to Ireland.
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Almost 10 years since the Department of Health established the strategic review of medical training and careers, tasked with agreeing measures to retain Irish trainees – I attended 20 review meetings between 2015 and February 2020 – the upward trend in Irish doctor emigration is relentless. Last year the 442 Irish doctors issued with temporary work visas to work in Australia was equivalent to 61 per cent of the 725 doctors who graduated from Irish medical schools in 2021.
Contracting consultants to work at night and weekends – envisioned in the new contract – without ensuring the availability of the teams of staff needed to make them productive, is probably a bigger disincentive for most than any theoretical or actual loss of income. In countries with mixed public-private health systems, such as Ireland, doctors often choose private practice for the assurance of having the necessary resources and care teams to enable them to use their skills, more than for the earning opportunities.
There is much of value in the contract which most doctors are rejecting. It includes a salary of which almost all other State employees could only dream; funding for continuing professional development and a commitment to facilitate research, which are measures essential to maintaining high-quality patient care.
However, sifting through the several hundred pages in 12 supporting documents on the HSE website reveals little to assure prospective consultants that they will have the essentials they need for productive work in the additional periods for which they will be contracted.
One document states that sufficient skilled staff will be rostered “to provide appropriate high-quality patient care and to meet anticipated service demands”. However, this is often not achieved during the hours that consultants are currently contracted to work.
Rejection of the offer by most of those surveyed – future consultants (64 per cent), consultants overseas (59 per cent), current contract holders (57 per cent rejection) – shows how little trust they have that the Department of Health and HSE will put in place the elements needed to make the new contract work for the benefit of patients.
The attention to the challenges of producing sufficient doctors to meet Ireland’s growing need in the Government’s March 2023 analysis of medical workforce supply report is to be welcomed. However, there is little new in it. Broadly speaking, we already graduate enough Irish/EU nationals to meet our needs but we don’t retain them,and we don’t get them back to Ireland when they have completed their specialist training abroad.
Ireland is not alone in facing such challenges. But we are an outlier among wealthy countries in the unremitting scale of emigration by the doctors we train, and in our relentless reliance on recruiting doctors from poorer countries who can even less afford to lose the doctors they produce.
Health-damaging working conditions are the main reason Irish-trained doctors won’t stay. These stem mainly from shortages of all frontline staff, including consultants, undermining training and requiring trainees and non-trainees to spend an inordinate amount of time on activities that lesser trained staff could and should be doing.
This piecemeal approach, looking to get agreement on a new consultant contract while neglecting the broader health workforce needs, is unlikely to work or be good value for money. Those who aspire to be consultants in Ireland need to know what will be done to ensure that there are nurses, other health professionals and resources needed to make hospital specialist-led teams productive, outside of current contracted hours, for the benefit for patients.
Negotiating a fair pay deal for consultants, which may be in the face of competition from other anglophone countries who often value Irish-trained doctors more than Ireland does, is a lot easier than putting in place the conditions of work that will prevent widespread disillusion, burnout and ongoing emigration by Irish doctors, who are a resource that we cannot afford to continue to lose.
Ruairí Brugha is emeritus professor of public health at the RCSI University of Medicine and Health Sciences