Ireland’s increasing need for doctors is mainly being met by employing foreign-trained doctors, according to a new report.
Despite achieving self-sufficiency, through graduating approximately 700 Irish doctors annually from the six medical schools in Ireland, the percentage of Irish doctors on the Medical Council register continues to fall. While the number of new entrants to the register doubled between 2012 and 2015, the numbers of graduates from outside Ireland who joined the register accounted for two thirds of all new registrants in 2015.
The report has been published by the RCSI Health Workforce Research Group.
Africa contributes the highest number of doctors with 28% and Pakistan supplies more than 20% of Ireland’s foreign-trained doctors. An important new pattern is the growth in the numbers of doctors trained in other European Union (EU) countries, which now represent 20% of foreign trained doctors. Graduates of medical schools in Romania, Hungary, Poland and the Czech Republic included not only nationals from these countries, but many non-EU nationals and a significant number of Irish nationals.
This new analysis, which summarises Medical Council registration trends, alongside data from the HSE’s National Doctor Training and Planning unit, also profiles the nationalities and countries of training of non-consultant hospital doctors (NCHDs) working in Irish hospitals.
While the numbers of NCHDs increased between 2011 and 2015, most of these were recruited to non-training posts. This means that efforts to put in place a specialist-delivered-health service are being undermined.
The report states that the systemic drivers of this growing medical workforce crisis include: i) high rates of emigration among graduates of Irish medical schools, attracted by better working conditions, training and career opportunities in other English speaking countries; ii) the need to be compliant with the European Working Time Directive, which restricts hospital doctors’ working week; and iii) increasing demand.
According to Professor Ruairi Brugha, RCSI Head of the Department of Epidemiology and Public Health Medicine, “We need high level recognition of the scale of the problem and we need radical responses, given the time and type of hospitals needed to train hospital specialists. Currently, Irish hospitals are employing increasing numbers of foreign-trained doctors into posts that don’t provide these doctors with an adequate level of supervised training. This is not good for patients, or for these doctors’ careers.
“The high turnover of such doctors confirms earlier research which shows that international recruitment is not an effective strategy; and many of those recruited are leaving Ireland for the same reasons that Irish doctors leave, a process we describe as: brain gain, followed by brain waste, ending with brain drain. This involves firstly a brain gain through the recruitment of non-EU trained foreign doctors.
“Then ‘brain waste’ through slow or stagnant career progression for these individuals leading to deskilling, and finally ‘brain drain’ through the onward migration of these doctors, mainly to other wealthy countries.”
The report states that Ireland needs effective retention measures to achieve medical workforce sustainability and to comply with our global responsibilities not to recruit doctors from poorer countries that can ill afford to lose their doctors. This means providing better working conditions (shorter and more flexible working hours); better terms and conditions (including equitable salary levels for new consultants); and more attractive training and clearer career paths for the doctors we produce.
The Royal College of Surgeons in Ireland (RCSI) Health Workforce Research Group has been researching health professional migration into and out of Ireland since 2006. Findings from these studies highlight that the same underlying weaknesses of the Irish medical workforce system – poor access to training, lack of career opportunities and poor working conditions – account for onward migration by foreign doctors and emigration by Irish-trained doctors. Joining the Brain Drain to Brain Gain project in 2015 has enabled the research group to review how the WHO Global Code has contributed to a greater awareness of the consequences of international recruitment by Irish hospitals on other source countries.
The Brain Drain to Brain Gain project provides an opportunity for the RCSI Health Workforce Research Group to express support for the equal relevance of the Global Code to a highincome country that recruits large numbers of doctors and nurses from low- and middle income countries, because of its inability to retain the health professionals that it trains. The project is using its strong knowledge exchange linkages – with the Medical Council of Ireland (MCI), the Irish Health Service Executive National Doctors Training and Planning (HSE-NDTP) Unit and the Department of Health – to focus effort on optimizing the use of routine data for more effective strategic planning and monitoring of the medical workforce, and thereby on health worker migration into and out of Ireland.
Medical workforce stressors continue to undermine Ireland’s ability to achieve medical workforce sustainability and compliance with the WHO Global Code on the International Recruitment of health personnel. These include: i) high rates of emigration among graduates of Irish medical schools, attracted by working conditions, training and career opportunities in other English speaking countries; ii) the need to be compliant with the European Working Time Directive, which restricts hospital doctors’ working week; and iii) increasing demand.
The result is that the increased domestic supply of doctors is not sufficient to keep Irish hospitals staffed, which recruit or employ doctors from low-and-middle income countries, such as Pakistan and Sudan, to fill this gap. However, this is only a stop-gap measure.
Ireland has implemented an innovative programme to provide structured postgraduate training to doctors from Pakistan – the International Medical Graduate Training Initiative (IMGTI). While popular, it is undermined by systemic medical workforce weaknesses, including the pressure on Irish specialists to provide training to its own graduates.
Since 2013, Ireland’s Health Service Executive (HSE) and Medical Council (MCI) have made progress in collecting and analysing routine medical workforce data, thereby generating medical workforce intelligence to inform national decision-making. The Brain Drain to Brain Gain project, run in Ireland by the RCSI Health Workforce Research Group has supported this national policy goal and Ireland’s compliance with the WHO Global Code, by linking these two sources of data so as to profile Ireland’s medical workforce by nationality and country of training.
Trends and patterns of International Medical Graduates registered to practice in Ireland.
Despite an almost doubling of the number of Irish/ European Union (EU) graduates from 370 to 725 per year between 2006 and 2015, the percentage of Irish graduates on the MCI register continues to fall, from 65% in 2012 to 62% in 2015, even as the numbers rise.
Pakistan contributes the most international medical graduates (IMGs). The proportion has been stable at 21-22% of registered IMGs between 2000 and 2015. However, the numbers have increased almost fourfold, from 375 (2000) to 1,481 (2015), which illustrates how domestic training is not sufficient to address rising attrition (emigration) and demand.
The review of historical MCI registration data shows changing patterns. The 28% of IMGs trained in sub-Saharan Africa include rising numbers of doctors registering from Sudan and Egypt; and falling numbers from South Africa and Nigeria.
A notable trend is the fast growth in numbers of doctors trained in central and Eastern European countries, who account for over 20% of IMGs. The increase in registered doctors trained in other EU countries from 9.6% (2012) to 13.2% (2015) of all registered doctors is mainly due to increases from Romania (from 193 in 2012 to 488 in 2015), Hungary, Poland and the Czech Republic.
Patterns in background of non-consultant hospital doctors (NCHDs) working in Ireland
Despite the national policy of a consultant (permanent specialist) led and delivered health service, the numbers of NCHDs, i.e. doctors in training and non-training posts, continue to rise. Reasons include the need to comply with the European Working Time Directive (see earlier); multiple small volume hospitals that require teams of NCHDs to provide 24/7 care; the time and resources needed to train specialists; and increasing demand for health care. HSE data show:
A 15.8% rise from 4,936 NCHDs in 2011 to 5,717 in 2015. This included an increase of 8.6% in those in formal training programme and a much larger 32% rise in non-trainee NCHDs. This shows that, despite a real effort and substantive increase in trainee posts, so as to deliver a specialistled service, there was an almost 4-fold greater increase in nontrainees in post.
In 2015, almost 77% of NCHDs not in training posts compared with 33% of NCHDs in training posts graduated outside Ireland.