Over one-third of doctors on general division of medical register

More than one-third of all clinically active doctors in Ireland are on the general division of the register, according to the Medical Workforce Intelligence Report for 2021, which has been published by the Medical Council. According to the Council, the high number of doctors in the general division represents a key risk to patient safety, “as while there is an increase in the general division, consultant and specialist posts are not being filled”.

The Medical Workforce Intelligence Report provides a detailed analysis of the Medical Council’s registration data, focusing on demographics of those retaining and withdrawing from the medical register in Ireland. Much of the report highlights deficits in the system and the resulting risks attached to patient safety and care.

The report contains significant findings, which “need to be addressed collaboratively amongst policymakers, educators, planners and employers”, according to the Council.

Key highlights:

• Overall, 21,680 doctors retained their place on the Medical Council’s register in 2021, with 18,424 or 85 per cent of those being clinically active.
• Of the active registered doctors in Ireland, 53 per cent were male and 47 per cent female.
• Over one-third of all clinically active doctors in Ireland are on the general division of the register
• The number of new doctors who registered in 2021 was 2,605, which represented a 14 per cent increase on the previous year.
• Of those, 1,717 were international graduates and 888 were Irish graduates.
• 49.8 per cent of NCHDs occupied non-training posts
• 62 per cent of doctors self-reported working more than 40 hours a week,
• Dublin has the largest number of working doctors with 7,426, which equates to 35 per cent of the total.

Significant withdrawals from the register

Of the 982 voluntary withdrawals recorded, 848 practitioners (86.4 per cent) completed the voluntary withdrawals form which outlines doctors’ reasons for voluntarily withdrawing.

Some 68 per cent withdrew from the general division, 25.4 per cent left the specialist division, and 3.5 per cent left the intern division. 25.5 per cent of doctors cited family or personal reasons for withdrawing from the register, while 17 per cent left because of limited career progression opportunities, up from 14.8 per cent in 2020.

A number of work-related issues were cited as reasons for withdrawing from the register. These included – resourcing, lack of appreciation, personal impact arising from excessive work hours and a lack of management or clinical supervision support. These points were emphasised as significant challenges to doctor morale and their capacity to deliver safe, quality patient care, therefore compromising patient safety

Other factors informing the decision of doctors to withdraw from the register include the cost of professional indemnity insurance and registration, an inflexible registration model, and health reasons associated with the Covid-19 pandemic.

Key risks highlighted:

For the first time in its Workforce Intelligence Report, the Medical Council is providing a summary of the key risks it has identified as part of the research project. Concern for patient safety is at the core of the five specific risks identified:

• General division – 34.9 per cent of clinically active doctors in Ireland are on the General Division. This represents a key risk to patient safety, as while there is an increase in the general division, consultant and specialist posts are not being filled.
• Non-consultant hospital doctors (NCHDs) – patient safety is further highlighted as there is a considerable proportion of NCHDs required to perform the duties of hospital consultants
• Reliance on international medical graduates (IMGs) – the majority of NCHDs are trained overseas and do not have access to specialist training in Ireland. The health service is over-reliant on IMGs who report being overworked, undervalued, experiencing discrimination and unable to access specialist training. Aside from the individual impact on the doctors, the treatment of IMGs has “serious implications for patient safety”.
• Non-compliance with European Working Time Directive (EWTD) – in 2021, over one quarter of doctors reported working more than 48 hours a week, in contravention of the EWTD. This has further serious implications for patient safety.
• Attrition – Acute doctor shortages within the Irish health system, especially at skilled and experienced consultant level, affect quality of care and can undermine patient safety. In 2021, doctors cited family and personal issues, lack of training opportunities, inadequate resourcing and work conditions as reasons for withdrawing.

President of the Medical Council, Dr Suzanne Crowe, said: “The wellbeing of doctors continues to be a central theme identified in the 2021 report and we need to address this, as we cannot afford the impact of this on patient care. There are many issues which range from non-compliance with the European Working Time Directive, to lack of career progression; non-hospital consultant doctors performing the work of hospital consultants; reliance on international medical graduates; and the poor treatment of junior and non-national doctors.”

“The risks are evident, we have unfilled consultant posts, there’s ongoing growth in the general division of the Medical Council register and our medical workforce continues to experience burnout, bullying and working excessive hours. The responses from those withdrawing from the register tell a story, and if we don’t accept, acknowledge and act on the deficiencies of our workforce now, patients will ultimately suffer.

“These factors lead to attrition from the register. They existed before the Covid-19 pandemic and yet remain to be addressed by the wider health system. There needs to be an urgency in looking at these and other related issues, as they lead to risking the care and safety of patients. Therefore, arising from the Report, the Medical Council has set out a series of key recommendations that will address the risks that have been identified

“There are numerous great projects underway or beginning on workforce issues at Governmental, national, training, employer and local levels but we must ensure that a collaborative approach is taken, involving all stakeholders including patients and educators, to ensure we address the issues highlighted in this report and other reports and research already published.”

Medical Council CEO Mr Leo Kearns said: “As part of our recommendations, the Medical Council is calling for a healthcare workforce strategy. This is something that needs to be seriously considered in the short term to address recruitment, retention, distribution and supply challenges. A framework for medical workforce planning should strategically consider and identify actions that will improve the working conditions of doctors. The objective is to arrive at a situation where there is a fit-for-purpose medical workforce, that results in high-quality patient care and safety.”

“The Department of Health, HSE and other agencies are leading out on, or commencing, some key transformational projects which will greatly improve access to care and treatment and these important developments must be considered when looking at workforce planning issues.

“While recent changes to legislation allowing access to training for non-EEA qualified doctors are very welcome, more needs to be done, as without access to career development, these doctors too will leave. NCHDs not in training report being over-worked, undervalued, experiencing discrimination and unable to access appropriate training. Current training, supervision and working conditions of NCHDs pose serious implications for patient and professional safety.”

“In addition, a major area of concern is the extremely high number of doctors in the general division of the medical register. This continued growth has largely been unplanned. It also reflects our disproportionate reliance on international medical graduates, who then have no career pathway or progression available to them. This in turn leads to high levels of voluntary withdrawal and emigration.

“All of this impacts on patient safety and our primary role as the regulatory body for the medical profession, is to protect the public. But in order to carry out our role effectively and address the risks that have been identified, we have to ensure that our workforce is working in a system that supports and helps them deliver care at the level people would expect – that’s a fundamental prerequisite. It requires a sustained commitment.”

Ms Bernadette Rock, Head of Research, said: “As the regulator of the medical profession, the Council has a duty to use our data to ensure that issues which can compromise patient safety are highlighted. The key risks identified from the data analyses and proposed actions set out in this report aim to support the planning and development of a strong and sustainable medical workforce that can provide safe, high-quality sustainable patient care.”

“It is only by working collectively with all stakeholders that we as a country can make real positive changes in healthcare delivery in Ireland and ensure continued high-quality care for our patients. The Medical Council can and will influence the required changes that are needed within the health system to support the provision of safe quality health care.”

Recommendations

The Medical Council said it strongly believes that the development and implementation of a strategic workforce framework for doctors, as an integral part of a wider workforce strategy, would be the most effective course of action. According to the Council, it will work in close collaboration with all stakeholders to ensure this happens. In support of this approach, the Medical Council highlights five recommendations for action:

• Commencing coordination and collaboration across all key stakeholders by setting up a Planning and Advisory Group to explore and plan workforce strategy
• Undertake a national consultation with individuals, patient groups and medical stakeholders to identify key priorities, issues, and challenges
• Identify priority workforce issues and contributing factors, determined by research and consultation
• Exploring the impact and feasibility or proposed approaches to ensure a fit-for-purpose approach
• The proposed strategy should not be developed in isolation, and health reforms and policies that are underway, including Sláintecare, Regional Health Areas, Healthy Ireland programmes and initiatives, national clinical programmes, and other developments should be considered.