Negotiating a work contract for the Gen Z doctor 

Irish Medical Organisation, Annual General Meeting, The Europe Hotel and Resort, Killarney, Co Kerry, 24-26 April 2025

Chair of the IMO NCHD committee Dr Rachel McNamara on why a new, fit-for-purpose contract for current and future NCHDs is essential

With various aspects of the world as we know it crumbling around us, a small item such as the renegotiation of a national contract is unlikely to have made it through your news algorithm. Nevertheless, it is both noteworthy – and dare I say, encouraging – that a new contract for non-consultant hospital doctors is presently under negotiation between the IMO, the HSE, and the Department of Health. This new contract for NCHDs was a condition garnered as part of the December 2022 agreement, which narrowly averted industrial action on the matter of rostering NCHDs to work illegal and unsafe hours. That agreement was to address critical and urgent matters pertinent to NCHD rights and welfare. It is hoped that a new contract will ensure that the systemic abuse of NCHDs will be confined to history.

Contract requirements

Negotiating a new contract for a group as diverse as NCHDs is like reviewing an x-ray on an outdated computer monitor. It’s very hard for everyone to be 100 per cent happy, but it’s important not to miss anything big. Doctors typically spend a minimum of 10 years as an NCHD and the term applies to everyone from interns on their very first day as a doctor, to senior registrars applying for consultant posts. In contract negotiations, it is usual for both the employer and the union to come with aims and objectives for what a new contract should look like. In 2023, the HSE’s main aim when negotiating the new consultant contract was clear: To abolish the provision of private practice in public hospitals. For the NCHD contract, the aims of the health service are not so clear cut. However, the aims of the IMO are simple and unapologetic:

▶ End the practice of breaching Organisation of Working Time Act (OWTA) working hour limits.

▶ Improve the working conditions of NCHDs to sustain the workforce into the future.

In place since 2010, the current NCHD contract, while making positive strides in some areas, ultimately failed to protect doctors from working illegal amounts. Despite explicitly stating within that contract it is the obligation of the employer to roster no more than the legal limit, the practice has continued. It would seem that stating the need to be compliant with the law has not proven to be a sufficient incentive. Therefore, protections need to be established in the new contract that make illegal rostering not just improbable, but impossible. Compliance, too, should mean 100 per cent compliance. Figures claiming 50, 70, or even 90 per cent compliance with the OWTA (ie, the law), would still not be cause for celebration. We wouldn’t celebrate being 90 per cent compliant with the law of not setting fire to people’s houses.

Protections

Such explicit protections for NCHDs are essential, as they are uniquely vulnerable within the system, by virtue of the fact that they are all temporary employees, rotate frequently between hospitals and different regions, and are often too browbeaten to stick up for themselves. In their 10-15 years as an NCHD, doctors have more bosses than most people have in a lifetime. While they are employed by each individual clinical site, they sign a contract with the HSE to provide service. Their line managers change every three months and their clinical directors change almost as frequently. On top of this, those on formal training schemes have programme directors, examiners, and faculties to satisfy. With the introduction of a new regional layer of governance, there is now an additional set of differentials to consider when switching sites – a fact that is often overlooked. It is clear that the 2010 contract left too much room for NCHDs to be exploited. In institutions where staff are overworked, this has been shown to be associated with adverse patient outcomes. This is a patient safety issue as much as anything else.

Future

It weighs heavily on the negotiating committee that this will be a contract that will have to see us through the next 10 or 15 years at a minimum. It must therefore appeal not only to today’s NCHDs – primarily millennials – but also to the next generation: The lesser known Gen Z cohort. Failing to do so will risk losing our future workforce overseas or to less demanding professions. According to Deloitte’s 2024 Gen Z and Millennial Survey, a smaller proportion of Gen Z employees view their work as central to their identity than the previous generation. In addition, according to the first National Doctors Training and Planning NCHD Survey 2025, over one-in-four NCHDs aim to work less than full-time in the future. This is a seismic shift from where the profession was 20 years ago, and one should argue, a good one. A health system does not need to feature NCHDs on the flat of their back. Future generations are just not going to put up with it.

Alongside a generational shift in ideology, the demographic changes in medicine need to be factored into these negotiations. The balance in most specialties, and in the profession overall, has tipped in favour of women, with women making up over 55 per cent of doctors in training. A new contract must take account of this, and incorporate protections both for the NCHD and for the system. When NCHDs express a wish to take full maternity or paternity leave, it should no longer send shockwaves across a department. Systems should not collapse when NCHD parents actually take their parental leave. Allowing NCHDs with caring commitments to take their statutory leave entitlements should not infringe on the rights of their colleagues by forcing them to have to work illegal amounts to cover the deficit.

Delivering care to the patients of the future will look different too. Patient-centred care (the model to which we all subscribe) cannot be delivered in a 10-minute clinic appointment without adequate clinical information or access to recent admission data and diagnostics. A new contract is an opportunity to equip NCHDs with the tools and training to be in a position to meet future demands and crises. It is an opportunity for shaping and securing a sustainable workforce, and positioning Ireland as an attractive place for medical graduates to train and be retained. We hope that this opportunity to do better will not be squandered by thinking small and by not being ambitious around what a well-resourced and sustainable workforce could look like.