The National and International Implications of a Decade of Doctor Migration in the Irish Context

Background: Between 2000 and 2010, Ireland became increasingly dependent on foreign-trained doctors to staff its health system. An inability to train and retain sufficient doctors to meet demand is the primary reason for the dependence on foreign-trained doctors. By 2008 the proportion of foreign-trained doctors was the second highest in the OECD. This increased dependence on international medical migration has both national and international policy implications. Methods: Registration data were obtained from the Medical Council of Ireland (MCI) for a ten year period: 2000-2010. Data indicate country of qualification but not nationality. The total number of registrants and entrants (n) was determined for each year. Immigration data were also obtained on the number of work visas issued to doctors. Registration and visa data were then compared in order to estimate doctor migration to Ireland 2000-2010. Results: The proportion of foreign-trained doctors rose from 13.4% of all registered doctors in 2000 to 33.4% by 2010. The largest increase was in foreign-trained doctors from outside the EU, rising from 972 (7.4%) in 2000 to 4,740 (25.3%) of registered doctors in 2010. The biggest source country in 2000 was Pakistan. By 2010, South Africa had become the biggest source country. The number of foreign-trained doctors from other EU countries doubled from 780 in 2000 to 1,521 in 2010. Conclusions: Registration data are likely to over-estimate and visa data under-estimate the numbers of doctors actively working in Ireland. However, they serve to illustrate Ireland’s rapidly increasing and potentially unsustainable reliance on foreign-trained doctors; and to highlight the need for better data to measure migratory flows. Improved measurement of health worker migration is necessary both for national workforce planning and to fulfil the requirements of the WHO Global Code on the International Recruitment of Health Personnel

Ireland’s international medical workforce: an analysis of linked medical council and medical workforce databases

The presentation covers 1.The profile of Ireland’s non-consultant hospital doctor (NCHD) workforce by nationality and country where graduated – for EU and non-EU countries. 2.Profiles (nationality and age) of foreign and Irish NCHDs working in public sector posts. 3.Types of posts filled by Irish/EU and non-EU NCHDs – training v non-training posts. 4.Lessons learned for policy and health workforce monitoring.</p

"We've all had patients who've died …": narratives of emotion and ideals of competence among junior doctors

Although there is reasonably rich literature on socialisation in medical schools, few studies have investigated emotional socialisation among qualified doctors; specifically how specialist training reproduces the norms, values, and assumptions of medical culture. This article explores expressions and management of emotion in doctors' narratives of work and training for insights into how socialisation continues after graduation. The study employed qualitative methods - in-depth interviews - with fifty doctors at early and advanced stages of specialist training in teaching hospitals in Ireland. The study found that performance of competence, particularly for doctors at earlier training stages, required them to hide signs of struggle and uncertainty. Competence was associated with being emotionally tough, which involved hiding emotional vulnerability; however, some challenged the assumption that doctors should be able to transcend emotionally painful events. Tensions between this expression of competence and making time for self-care meant that the latter was often neglected. Some participants highlighted how they enjoyed more personal interactions with patients, which was juxtaposed with the expectation of being detached and an associated potential to objectify patients. This theme resonates with recent debates on "appropriate" expressions of empathy and its implications for patient-doctor relationships. The article discusses how ideas underpinning the image of medical invincibility should be questioned as part of efforts to reform medical culture and in the training of specialists in emotional wellbeing and self-care

Brain Drain to Brain Gain: Ireland's Two-Way Flow of Doctors

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 –see http://www.healthworkforceireland.com/braindrain- to-brain-gain-project.html, 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.</p

“We’re not there to protect ourselves, we’re there to talk about workforce planning”: A qualitative study of policy dialogues as a mechanism to inform medical workforce planning

AbstractIntroductionTo address a disjuncture between medical workforce research and policy activities in Ireland, a series of national level policy dialogues were held between policy stakeholders and researchers to promote the use of research evidence in medical workforce planning. This article reports on findings from a qualitative study of four policy dialogues (2013-2016), the aim of which was to analyse policy dialogues as a mechanism for knowledge-sharing and interaction to support medical workforce planning. MethodsDescriptive qualitative study design involving in-depth interviews with policy stakeholders and researchers (n=13) who participated in the policy dialogues; thematic analysis of interview transcripts. FindingsPeriodic policy dialogues, with discussion focused on research evidence, provided an enabling environment for exchange and interaction between policy stakeholders and researchers, and between policy stakeholders themselves. Findings foreground the significance of the policy-making context, in terms of how people interact during policy dialogues, and how research can potentially (or not) inform medical workforce planning. ConclusionPolicy dialogues provide a mechanism for improving knowledge exchange and interaction between policy stakeholders and researchers. Situated within the policy context, policy dialogues also add value to: a) policy-making processes by facilitating interactions between policy stakeholders outside the day-to-day business of formal and sometimes adversarial negotiation; b) research processes, including exposing researchers to the complexity of health workforce planning, and health policy more generally. </p

NCHD emigration crisis and the need for consultant-delivered care.

Well-trained and motivated medical staff are essential to a functioning health system. However, Ireland is struggling in this regard. As has been highlighted in numerous studies and reports over the years, Irish non-consultant hospital doctors (NCHDs) are demoralised and dissatisfied with working conditions in Ireland and are leaving in increasing numbers. The other side of the coin is Ireland’s growing reliance on overseas-trained doctors, despite the successful scaling-up of numbers of EU (and therefore Irish) entrants to medical schools.</p

Global Surgery Priorities: A Response to Recent Commentaries.

We welcome the five published responses1-5 to our editorial,6 which outlined a research agenda for making surgery accessible in low- and middle-income country settings, where it is most needed. The commentators represent a good mix of academics, researchers and advocacy specialists, which demonstrates the growing global commitment to working together in the ‘empirically evolving global surgery systems science.’3 There is considerable consensus in the messages, including the importance of collaborative research approaches, adapted to country contexts; a focus on district population needs; and the use of standardised routine data collection and evaluation methods. Here, we briefly touch on some important new perspectives and some diverging ones.</p

From Brain Drain to Brain Gain: Ireland's nursing and midwifery workforce

Year 3 of the Brain Drain to Brain Gain project, building on earlier research on nurse and doctor migration, focuses on accessing and utilizing available routine data to generate up-to-date evidence on the inward and outward migration flows of Ireland’s nursing and midwifery workforce.</p

Failing to retain a new generation of doctors: qualitative insights from a high-income country.

BACKGROUND: The failure of high-income countries, such as Ireland, to achieve a self-sufficient medical workforce has global implications, particularly for low-income, source countries. In the past decade, Ireland has doubled the number of doctors it trains annually, but because of its failure to retain doctors, it remains heavily reliant on internationally trained doctors to staff its health system. To halve its dependence on internationally trained doctors by 2030, in line with World Health Organisation (WHO) recommendations, Ireland must become more adept at retaining doctors. METHOD: This paper presents findings from in-depth interviews conducted with 50 early career doctors between May and July 2015. The paper explores the generational component of Ireland's failure to retain doctors and makes recommendations for retention policy and practice. RESULTS: Interviews revealed that a new generation of doctors differ from previous generations in several distinct ways. Their early experiences of training and practice have been in an over-stretched, under-staffed health system and this shapes their decision to remain in Ireland, or to leave. Perhaps as a result of the distinct challenges they have faced in an austerity-constrained health system and their awareness of the working conditions available globally, they challenge the traditional view of medicine as a vocation that should be prioritised before family and other commitments. A new generation of doctors have career options that are also strongly shaped by globalisation and by the opportunities presented by emigration. DISCUSSION: Understanding the medical workforce from a generational perspective requires that the health system address the issues of concern to a new generation of doctors, in terms of working conditions and training structures and also in terms of their desire for a more acceptable balance between work and life. This will be an important step towards future-proofing the medical workforce and is essential to achieving medical workforce self-sufficiency.</p

It’s the economy, stupid! When economics and politics override health policy goals – the case of tax reliefs to build private hospitals in Ireland in the early 2000s [version 2; referees: 2 approved]

Objectives: To analyse the policy process that led to changes to the Finance Acts in 2001 and 2002 that gave tax-reliefs to build private hospitals in Ireland. Methods: Qualitative research methods of documentary analysis and in-depth semi-structured interviews with elites involved in the policy processes, were used and examined through a conceptual framework devised for this research. Results: This research found a highly politicised and personalised policy making process where policy entrepreneurs, namely private sector interests, had significant impact on the policy process. Effective private sector lobbying encouraged the Minister of Finance to introduce the tax-reliefs for building private hospitals despite advice against this policy measure from his own officials, officials in the Department of Health and the health minister. The Finance Acts in 2001 and 2002 introduced tax-reliefs for building private hospitals, without any public or political scrutiny or consensus. Conclusion: The changes to the Finance Acts to give tax-reliefs to build private hospitals in 2001 and private for-profit hospitals 2002 is an example of a closed, personalised policy making process. It is an example of a politically imposed policy by the finance minister, where economic policy goals overrode health policy goals. The documentary analysis and elite interviews examined through a conceptual framework enabled an in-depth analysis of this specific policy making process. These methods and the framework may be useful to other policy making analyses.</p