Dr. Niamh Humphries:

I thank the committee for the opportunity to present our research to it this morning. The hospital doctor retention and motivation project, HDRM, is a research project that is funded by the Health Research Board, HRB, and is based at the RCSI graduate school of healthcare management. The HDRM team comprises Dr. John-Paul Byrne, Dr. Jennifer Creese and me. We are all present this morning. We have submitted a briefing statement, which contains additional detail on each component of the HDRM project.

For the past four years, the HDRM team has researched doctor retention and the working lives of hospital doctors in Ireland. We have interviewed emigrant Irish-trained hospital doctors in Australia and have surveyed and interviewed hospital doctors in Ireland about their working conditions. Over the past two years, we have undertaken research on how the pandemic altered the working conditions, well-being and work-life balance of Ireland’s hospital doctors.

A key aim of the HDRM project is to connect policymakers and hospital doctors. We want to provide policymakers and medical workforce planners with the organisational intelligence they need to inform improvements to medical workforce policy and practice. In doing so, we want to help them to see the everyday work, as is done by hospital doctors, rather than the work as is imagined.

Policymakers are often surprised at our research findings and are unaware of the many challenges faced by hospital doctors. One reason for this is that hospital doctors are rarely asked about their working conditions. Another reason is that hospital doctors, like many health workers, do not always feel safe to speak up about the challenges they face at work. They have told us that sometimes they do not speak up because they fear it might damage their career or cause further deterioration in their working conditions. Others do not speak up at work because they feel it would not change anything.

Among emigrant doctors in Australia, there was a sense that exit via emigration was a less risky option than speaking up. It is difficult to see how change will happen in a situation where policymakers are unaware of the challenges that are faced by hospital doctors, hospital doctors feel powerless to improve their working conditions or the system and emigration remains a viable option for those hospital doctors who are seeking to improve their working conditions.

The HDRM project has sought to bridge the gap between policy and the front line by inviting hospital doctors of all grades to speak to us in confidence about their experiences of working in the Irish health system and for us to then share these anonymised insights with policymakers. We are delighted to have the opportunity to present our findings to the Joint Oireachtas Committee on Health.

Since 2018, we have surveyed and interviewed almost 1,200 hospital doctors about their experiences of working in the Irish health system. We have interviewed 51 Irish-trained doctors in Australia about their decision to emigrate. We have surveyed 1,070 hospital doctors in Ireland about their working conditions. We have interviewed 48 hospital doctors about working through the first wave of the pandemic. Most recently, from July to December 2021, we conducted a remote ethnography with 28 hospital doctors. This involved interviewing each doctor twice and engaging them in a WhatsApp conversation about their working conditions over a 12-week period. This is what we learned about their experiences of working in the Irish health system in 2021.

We found that the hospital doctors we spoke to are really struggling. Both non-consultant hospital doctors, NCHDs, and consultants are finding it hard to manage long working hours and a work-life balance that is heavily skewed in favour of work. The pandemic appears to have intensified already difficult working conditions. Respondents spoke to us about the challenge of working in a health system that feels understaffed and under-resourced. Although they occasionally worked on adequately staffed teams, this was a rare occurrence.

Having too few staff to meet the demand for care impeded their well-being, but also restricted their ability to plan and improve services. Doctor 6 said: “It’s like we’re in a constant state of crisis now which makes it very hard to take a breath or plan for the future.” Doctor 11 said: “We’re all burned out ... I have gone from someone who was happily jumping out of bed to work to dreading it.” The hospital doctors we spoke to felt they could provide better patient care if they were better supported at work, that is, if the health system was better staffed and better resourced. Doctor 7 said: “I find myself apologising to patients on behalf of the system for their poor care. It’s draining.” Doctor 5 said: “What keeps me up at night is ... people not having access to timely care.” Respondents found it difficult to see their patients struggle to access the care that they needed.

Doctors also spoke to us about challenging relationships at work, particularly with hospital administration, HR and hospital management. For NCHDs, this related to their vulnerability as temporary employees who regularly move hospitals. NCHDs spoke about being underpaid for their work, either in being placed on an incorrect pay scale or in being underpaid for the overtime they have worked. As temporary employees, NCHDs found it difficult to resolve these issues, as this respondent explained:

NCHDs ... are never around long enough to implement change. Only there for 1 to 2 years max and moved to new hospital. Just very easy for management not to listen.

For consultants, there was a feeling that interacting with hospital management was a frustrating experience and was of limited value in bringing about change. This dissuaded them from initiating change in their hospitals, as these doctors explain. Respondent 1 said:

I've said all that before. No one would listen. Nothing changes. So that leads to disengagement ... just say nothing because, you know, saying stuff gets you nowhere ... and it just makes you feel bad. You don't change anything but you just get all het up about it and that's really exhausting.

Respondent 16 said:

Having spent my first [number of] years as a consultant as someone who innovates/sets up services/improves/pushes/advocates. I am now resigned to simply doing the job and keeping away from management as much as I can. It’s too damaging having any interaction with them.

Both NCHDs and consultants felt under-valued by the HSE and held out very little hope for health system improvement. While they were deeply unhappy with many aspects of the health system, they also appeared resigned to it. Although they recognised that they could provide better care if better resourced to do so, they had accepted that this was unlikely to happen. Instead, they resolved to do their best for the patient in front of them. As doctor 4 explained: “Being facilitated to do the job well and efficiently is the type of recognition I would like.”

Respondent hospital doctors appeared to waste considerable time and energy struggling with difficult working conditions, inefficient systems and challenging workplace relationships. Gaining access to appropriate care for their patients or initiating even minor improvements at hospital level involved engaging in ‘‘hand-to-hand” combat with the system. Should it really be this difficult?

Overall, HDRM research findings across four years of research reveal a medical workforce that is struggling rather than thriving. They describe a health system in which both hospital doctors and their patients are upset and frustrated, disappointed that the system is failing them both. If the health system is to recover from the pandemic, reduce hospital waiting lists, ensure timely access to healthcare and deliver on Sláintecare reforms, it will need to strengthen its medical workforce. Recruitment, retention and return emigration are all critical to medical workforce strengthening and they will all require substantial improvements to the working conditions of Ireland’s hospital doctors.