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Doctors in Ireland: Not the retiring types?

As consultant anaesthetist Dr Enda Shanahan approached his 65th birthday three years ago, he was fit and healthy and still running marathons.

The experienced doctor wanted to continue working and was meeting his obligations to maintain knowledge and skills under the Medical Council’s continuous professional development process.

But despite his wealth of experience and commitment to the public health service, his offer to continue working was rejected. Instead of celebrating his milestone birthday, the anaesthetist was left feeling “useless”. Retirement at 65 was mandatory under his contract.

The rule still applies to consultants working in the public health service, although GPs had their right to work extended until they reach 72 under their last contract with the HSE.

The mandatory retirement age is in place, despite the ongoing recruitment difficulties in the health service and the predicted surge in retirement levels facing the medical profession. The Medical Council’s Medical Workforce Intelligence Report (2016) showed that about a third of specialists on the medical register, including GPs, were aged 55 or over.

The proportion of older doctors varied across specialties, with almost six out of 10 public health medicine specialists aged 55 or over. Slightly over a third (34 per cent) of GPs were aged over 55.

Wider benefits

Speaking about his own situation to the Medical Independent (MI), Dr Shanahan commented: “Eighteen months before [retirement], I had written to Minister [Brendan] Howlin who was the Minister for Public Expenditure and Reform at the time, just pointing out that there would be benefits to the country and there would be savings by keeping somebody like me working.

“So I wrote to the Minister for Public Expenditure and I made my case. They took a long time to reply and when they did, I had a rather short reply telling me it was a matter for the Minister for Health and at that time it was James Reilly.

“I wrote to James Reilly and he responded quickly and said ‘at 65, you have to retire’. There was no question of discussing the shortages that we had in the health sector or the potential savings to the country in keeping people working longer.”

Dr Shanahan said he unwillingly retired from his post at a Dublin hospital. “Suddenly I was useless. That would have been fine if I had wanted to go off and play golf all day, every day, or go and lie on a beach in Lanzarote permanently, but I didn’t want those things. I didn’t feel ready for that.

“People say it is like walking off a cliff and that is very real, because the day I retired, I was doing everything I was doing for previous years; same big operations I had been doing. I was doing oesophagectomies and pancreatic surgery. We were doing big stuff and I could still do it. The surgeons I worked with didn’t want me to retire. But they didn’t have any input into that, nor did the nursing staff.”

Job satisfaction

He continued: “If you are enjoying your work and you have job satisfaction, you don’t see any reason to stop. I wasn’t just fighting age, in denial about my age. Work was more satisfying. The kind of work I went into medicine in the first place to do. For most of my life, it would have been like that.”

He said that for someone mainly committed to the public sector, like him, there is minimal private practice to turn to as an option after retirement from the public sector.

St Patrick’s Mental Health Services in Dublin, where he worked on Tuesdays, had no issues with his age and kept him on.

Dr Shanahan looked at his options and considered moving to the Middle East to work, “which a lot of colleagues had done”. But he eventually got locum work at University Hospital Waterford, which “kept him going” for about six months.

 “That was about four-to-five days a week. They were very happy to have me there; they were short-staffed. I was happy to be there and it kept me working and it kept me going.

“But every Sunday evening I had to drive down to Waterford, where I stayed in a B&B until Friday and then I came back to Dublin for the weekend. I don’t have young children so it wasn’t so bad, but after a couple of months of that, I thought ‘there has to be a better way to do this’. The next thing, after a while looking, I managed to find some locum work in Cappagh Hospital; again, great colleagues to work with.”

Dr Shanahan added: “Then eventually an opening came here at Tallaght on a specified-purpose contract — they needed an anaesthetist for the ECT service, which would be the two days a week. That is what I have been doing since October 2015.”

The difference that one doctor can make

Renowned kidney and pancreas transplant surgeon Mr David Hickey took early retirement from his post at Beaumont Hospital, Dublin, at the end of 2014. He was aged 63 at the time.

The pancreas transplant programme moved to St Vincent’s University Hospital, Dublin, after Mr Hickey’s departure from Beaumont.  St Vincent’s confirmed that the first pancreatic transplant was carried out at the south Dublin hospital in “recent” months. It marked the first pancreatic transplant in the Republic of Ireland since Mr Hickey’s departure. It is understood the programme’s commencement at St Vincent’s was delayed due to recruitment and training issues.

Speaking from Dubai, Mr Hickey said he offered “to stay on twice, with offers one year apart, to mentor a replacement” to carry out pancreas transplants in Ireland.  He said the offer was acknowledged by the HSE but not accepted.

Mr Hickey is now doing pioneering surgery abroad and carried out the first kidney transplant in Dubai in June last year. The operation took place at the Mediclinic City Hospital.

Agency costs

The anaesthetist points out that the HSE has engaged many healthcare workers who are employed by agencies and a certain number would be people who retired, willingly or unwillingly, and then came back.

“It costs the taxpayers more because the agencies, not only will they get top rate for the doctor or the nurse, but they also have an agency fee for providing that person. So it is an expensive way to replace people. It would make better sense to keep workers on who are fit-for-purpose.”

Dr Shanahan said there is a real need for “an objective way” of assessing doctors as to whether they are fit to do their job, regardless of age.

He said: “The Medical Council has its continuing medical education and continuing professional development and there are things we have to do; we have to comply with so many educational activities of different types that are being carried out in the previous 12 months and there is a set amount that has to be achieved over a five-year period.”

This approach only goes so far and there needs to be a method adopted that can examine the competency of doctors irrespective of age, he suggests.

“It’s not just [about] older people. But it’s the kind of thing that will need to be introduced if doctors and other workers want to work on… they will say ‘you have to prove you can do the job’.”

Canadian approach

In November 2015, Dr Shanahan called for the abolition of the mandatory retirement age before the Joint Oireachtas Committee on Justice, Defence and Equality.

He pointed to the Canadian model: “In Canada, for example, 12,128 physicians aged 65 and over are still working, comprising 15 per cent of all doctors there. Another 25 per cent of doctors are in the 55-to-64 age group.

“Most of them will continue to work after 65 because the Canadians deal with this by having an assessment of fitness to practise. They use a questionnaire for those who have been in practice for more than 35 years. If a warning flag is raised, such as in the case of a doctor who has been working for 35 years or more, or a doctor who is working solo as a locum with not much contact with the others, there is a further review. It works well for the Canadians.”

Legislation is on the horizon to defer the age of retirement for key medical professionals. But Dr Shanahan fears that “there will only be a carcass left” when it is finally introduced.

He said: “What I would see is that it wouldn’t be mandatory, that it would be optional. There will be people who not only want to retire at 65 but some of them earlier because they are burned-out, because they have had too much of stressful jobs.”

‘Perfect storm’

Mr Chris Goodey, CEO of the NAGP, told MI the pace of recruitment is simply not meeting the ongoing and predicted surge in retirement.

Mr Goodey said the number of GP training places has been increased to try and cope with demand, but the move is not enough in the short term as more and more graduates head abroad for work to Australia, New Zealand and Canada. He said the specialty of general practice is becoming “less attractive” because of current conditions.

The NAGP CEO told MI that very few GPs opt to stay working until they are 72.

He said the “perfect storm” is on the horizon as the system struggles to retain GPs under the current contract conditions and the forecasted rate of retirements.

“It’s going to have a catastrophic impact. We are going to end up inevitably with waiting lists for patients. We are currently seeing all around the country waiting lists of up to 10 days in some places — the norm would be three days to see your GP, but you can imagine when there are a lot less GPs, then we could be like the NHS when you are seeing up to three-week waits.”

He said GPs in the Irish system are “very proud that they have been able to deliver certainly same-day urgent cases or certainly within 24 hours, but that’s going to be a thing of the past. We are at the edge of a cliff now. We are fighting hard to speed-up the process of a new contract. At the rate it is going, it could be two-to-three years before a new contract.”

The NAGP has conducted a survey of GPs on issues relating to retirement, with the data currently being analysed.

Mr Martin Varley, Secretary General of the IHCA, said a “significant” number of consultants will be retiring shortly, no matter how one calculates the figures.

“The figures we have, which exclude GPs who are on the Specialist Register, show 10 per cent over 60 and a further 15 per cent between 55 and 59. What that means is that 10 per cent of the specialist hospital consultants are 60 or over, which is 250 or so. It could be more, they could be retiring any time soon and a further 15 per cent — up to about 400 — could retire within five years or less,” Mr Varley said.

“That’s a significant number, no matter how you add it up — a total of 25 per cent of the total existing consultant cohort. The other significant question you have is, what is the impact on the delivery of services? [The] consultant recruitment and retention crisis is already impacting on all specialties and hospital types, across the range.

“We know that there over 400 permanent consultant posts which are not filled. Some have been filled on a temporary basis. That is 15 per cent of the existing permanent approved consultant posts.”

Senator and GP pushing for retirement deferral Bill

Proposed legislation to allow key health professionals defer retirement from the health system has been published by Senator and GP Dr Keith Swanick. 

Senator Swanick, Fianna Fáil’s Seanad Spokesperson on Health, introduced the Bill in the Seanad in March, with the second stage taken in April.

The Government asked for leave for six months to allow time for publication of the Department of Public Expenditure and Reform’s review of barriers to extended participation in the public service workforce. This review is already underway.

Depending on the outcome, Senator Swanick will be pushing ahead with his Bill when the Houses sit again in October.

Senator Swanick told MI: “It’s somewhat ageist to think that people would have to retire because of an arbitrary age on the calendar, especially people who have lots of expertise and knowledge and experience. Often, a consultant may be forced to retire and they might be in a very unusual specialty and there could be an 18-month gap before there is a new consultant.”

The legislation is designed to allow critical health professionals to postpone their retirement for two years under mutual agreement with their respective employers.

The proposed ‘Dual Consent’ process to facilitate this would require the written consent of both employee and employer. This written consent must be in place before the employee reaches the mandatory retirement age. The agreement would include the time frame permitted for an extension of employment, which may be up to two years initially and may be extended once for a further two years, as long as the ‘Dual Consent’ remains in place between both parties.

The new rules, if passed, would apply to key nursing, medical and consultant personnel within the health service, including organisations funded directly by the HSE, the Department of Health and all the major health service providers.

Senator Swanick said: “It’s a Bill that is not going to go away. I would be hoping that when they come back in September that they will accept my Bill in full without any amendments. I’m quite happy to look at any sort of amendments or suggestions that they might have at that time.”

The health service “cannot afford to be losing consultants that are highly trained” and it will be “ageism at its absolute worst” if the Bill isn’t enacted.

A HSE spokesperson said that, based on a 75 per cent completion rate of the national doctors’ information management database, there are 20 consultants reaching retirement age in 2017.

The Executive said full information will be available when all clinical sites and mental health services “complete population of this database”.

It confirmed that, over the course of the current year, approximately 30 GPs will retire from the GMS. However, Senator Swanick dismissed the HSE’s predicted level of consultant retirements as “misleading”.

“Twenty may be a relatively small number but you can’t quantify the amount of patients that those consultants will see and the amount of complex procedures that they would carry out. Twenty is a misleading number. It gives false reassurance to the public in a way. The output of work [of] those consultants is immeasurable,” he said.

According to the Medical Council, there are no provisions for age restrictions in the Medical Practitioners Act 2007. A doctor can be registered with the Council at any age, provided they pay their registration fee and maintain their professional competence requirements.  “Mandatory retirement ages are entirely at the discretion of the employer,” said a spokesperson.

In a statement to MI, the Department of Health said the mandatory retirement age is a public service-wide issue and not unique to the health service. It said the terms and conditions of employees in the public service are generally a matter for the Minister for Public Expenditure and Reform.

“In this context, an Interdepartmental Working Group on Fuller Working Lives, chaired by the Department of Public Expenditure and Reform, was established in early 2016 to examine issues from prevailing retirement ages for workers in both the public and private sectors.

“The Report of this Group was agreed by Government in August 2016. The report identified a set of framework principles to underpin policy in the area and made a number of recommendations assigned to Government Departments and employer bodies for follow-up.  On foot of the recommendations in this report, the Department of Public Expenditure and Reform has been tasked with reviewing the current statutory and operational considerations giving rise to barriers to extended participation in the public service workforce up to and including the current and planned age of entitlement to the contributory State pensions.

“This work is currently underway and expected to be completed in the second quarter of 2017.  Any future proposals will be considered in the context of the outcome of the work of this group.”

Specialist Register

The IHCA is also concerned that an increasing number of temporary consultant posts are being filled by doctors who are not on the Council’s Specialist Register. The Association said this practice violates the most basic professional standards within the public health services. Currently, 128 doctors are working as consultants in public hospitals who are not on the Specialist Register, according to recent statistics issued by the HSE to Sinn Féin’s Health Spokesperson Louise O’Reilly TD.

Mr Varley said: “We are quite concerned that the HSE would appoint people who are not on the Specialist Register. The HSE has responded in the last two weeks that that is only when they are appointing specialists who are in their final year of training in an acting-up position, but it is more widespread than that.”

The IMO has also raised concerns over the recruitment and retention crisis.  A spokesperson said one-quarter of advertised consultant posts receive no applicants, and, according to its research, over half of Irish-trained medical graduates plan to practice medicine abroad. It described these figures as “without precedent in the history of the Irish public health service”.

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