Our Healthcare System Needs Support

Image Credit: Dominic Daly

The IMO announced this week that up to 600 doctors may leave the health system by July.Daniel Boland asks what can be done to retain doctors and to keep our healthcare system fromcollapsing?

The story of Irish doctors going to work abroad is not a new one. As a medical student working in
any given Irish hospital, it is more likely than not that the doctor you are working under will regale
you with unsolicited tales of their glory days in Australia. Indeed, in 2012 a report commissioned by
Fine Gael found that 65.5% of final year medical students at the time planned to leave the country.
This does not tell the full story, of course. A fair chunk of that 65.5% did indeed leave the country to
spend a few years adventuring and having new experiences. The experiences of both being on
another continent and of working in a healthcare system that was not creaking on the brink of
collapse. For most, it was a temporary measure while the country was in the grips of recessionary
cuts. So, in what is termed circular migration, many doctors emigrated for a while before eventually
returning home to Ireland. But as time has gone on and the recession faded into the past, hopes for
an improvement have died. In short, this is an old problem, however the IMO’s recent
announcement is a warning that it is reaching critical mass.
There are both push and pull factors that influence where doctors go. Pull factors attract doctors and
include higher wages, lower-stress jobs, access to specialist training programmes and opportunities
to participate in interesting research. We can do little to influence the pull factors that other
countries offer, as tempting as it might be to send a crack team of HSE spies to sabotage all the MRI
machines in Adelaide. What Ireland can do is reduce the push factors. These are the things that
make it undesirable to work here. Anecdotally, understaffing and overworking arise as the major
issues that push people to breaking point. As part of their statement on the up to 600 non-
consultant hospital doctors potentially leaving the country this summer, the IMO referred to ‘long
working hours and chronic manpower problems’. In 2018 there were 349 unfilled consultant jobs. A
detailed study of doctor migration between 2008 and 2018, from which this article draws many of its

conclusions, confirmed that a major draw of Irish-trained medics to Australia was the reputation for
‘good working conditions for health workers and good staffing levels’.
Doctors are only one part of Ireland’s healthcare machine. Nurses have similar workplace problems
that equally need to be addressed. So too do allied health professions and all the general support
staff that help hospitals to run. Fundamentally, the HSE needs to value its workers. Certain hospitals
are well-staffed and do not suffer from overworking problems, but they are the exception rather
than the rule. A vicious circle is created where a poor work environment leads to workers leaving.
This creates staff shortages which leads to an even worse work environment and more vacancies.
Indeed, the work shortages are tied. Doctors are incapable of functioning without nursing support,
while nurses spend ages chasing down doctors. It all leads to overtime, stress and unhappiness.

Covid has created a difficult situation for the HSE. Healthcare systems will never have enough money
at the best of times. Improvements in patient care are always possible. Therefore, the age-old
economic question arises of getting the best value out of the money that you have. 2021’s HSE
Budget saw an increase of 21% or €3.5 billion, half of which was for non-covid services. There are
many worthy ways for that money to be spent. But in a healthcare system which is repeatedly
referred to as in crisis, no overarching plans have been made to attempt to break the cycle of
manpower shortages.

In the wake of the covid-19 pandemic in April 2020, then-Taoiseach Leo Varadkar announced the
creation of 300 additional jobs for medical interns. Intern in this context is a rather confusing term,
but rather than being the person doing the coffee run, these interns are qualified doctors in their
first year of work after graduation. Interns perform a huge amount of the medical work in a hospital
setting, ordering bloods, inserting cannulas, writing up prescriptions, filling in charts and discharge
letters, doing patient rounds and most crucially flagging their more senior colleagues when a patient
deteriorates. So as the first wave of covid hit and great uncertainty lay ahead, it was decided to offer
intern jobs to all medical graduates from Irish universities. This was widely well-received. The more
doctors the better during a pandemic, after all. This recruitment drive was not the usual state of
affairs. The number of intern posts available before 2020 was tied to the number of CAO places in
medicine. CAO applicants are prioritised in the allocation system, guaranteeing jobs for all Irish
graduates. What this meant was that every year before last, a large number of the international
graduates from Irish universities did not receive job offers.

This year, the HSE’s National Doctors Training and Planning Unit says it plans to bring intern places
back down to ~750 from ~1100 last year. The money saved by this cut would be around €12 million.
The rationale given is that last year was a time of exceptional circumstances and that the hiring
decision was political. The arguments that have been made in favour of this position have centred
around lack of funding and concern around the training capacity of the HSE. There may be some
weight to these arguments, but a single statistic does a significant amount to refute them. In 2019,
before the job numbers were temporarily increased, 33% of interns worked more than 60 hours a
week. This figure shows that the problem of understaffing and overworking is something doctors
deal with from the very beginning of their careers. This is what drives the culture of emigration. The
underlying problem that is highlighted by this is a failure to treat the wellbeing of staff as a priority.

An ongoing intercollegiate student-led campaign under the hashtag KeepOurDoctors is hoping to
reverse the decision to roll back the job numbers. The students in question have lived and studied in
Ireland for the last four to six years. Previously, it has been much lamented that ‘the emigration of
doctors is eroding return on recent state investment in basic medical training in Ireland’. This
statement is on the basis that the quality of medical education in certain countries is not up at the
level of that in Ireland. And as Irish graduates leave, more and more places are filled by
internationally trained doctors who may have poorer training. It should be noted in the case of the
abovementioned intern jobs, that the students hoping to remain in Ireland may be of international
origin but are Irish-trained.

The Irish healthcare system has a vast number of multifaceted issues that need to be addressed,
ranging from waiting lists to trollies to the handling of the still-ongoing pandemic. But one part of
the solution is in a systemic response towards valuing the staff currently employed, by listening to
their needs, by improving their working environment and by striving to retain them. Hiring 300
doctors who want to stay and work in Ireland is a step in the right direction.