Do we pay trainee doctors too much?

  • Niall Hunter, Editor

Many column inches and much airtime has been taken up in recent weeks with the pay and work practices of hospital consultants.

Now, with a new consultant agreement in place, consultants will presumably in future work more flexibly and newly-appointed consultants will earn less.

While there are many caveats about the recent consultant agreement and how the new arrangements will work out, most of us will welcome any move to get better value for money from our consultants.

However, the search for better value should not end with specialists. The public perception, largely accurate, is that we pay our doctors too much, especially in comparison to other countries.

However, this perception usually centres on fully-trained doctors; for example, hospital consultants and GPs.

The spotlight is seldom turned on the people working towards becoming specialists. - junior, or non-consultant hospital doctors - in effect, trainee consultants and GPs. These trainees who are still learning their trade can be paid quite a lot.

There are more than 4,500 of these doctors in the health system, most of whom work hard, work long hours and have a good level of clinical skills.

We undoubtedly train our young doctors to a high standard - this is as it should be, however, considering how much it costs us to train them.

Due to the skewed nature of our hospital service, which will hopefully change with the appointment of extra consultants and greater consultant work flexibility, we rely far too much on junior doctors to provide the bulk of the day-to day routine patient care in public hospitals. While changes may be afoot, for the moment we still essentially have a consultant-directed, rather than a consultant-provided hospital service.

Ideally, the future picture should be that we will have more consultants on the floor in hospitals directly providing care, and fewer trainee doctors providing this care. Hopefully too, we will have fewer patients going into major hospitals for treatment of relatively minor complaints, with more emphasis on treatment in primary care or local community hospitals.

However, whatever way the reforms work out, we will undoubtedly still rely well into the future on a certain number of junior, trainee doctors to provide a good deal of everyday hospital services.

The next item on the reform agenda for Health Minister James Reilly should be to tackle yet another expensive anomaly in our healthcare system. The fact is, well ok, the opinion is, in these straitened times, the taxpayer is footing too large a bill to train today's doctors.

The key word here is 'trainee'. These doctors are being trained to be specialists, yet some are already approaching specialist-type pay.

In fact, a minority are already on pay, including overtime, that is in excess of the newly-reduced pay rates set for new entrant consultants of around €120,000.

Basic junior doctor salaries in Ireland range from €30,000 for an intern just out of medical school to €76,000-€79,000 for a specialist or senior registrar at the top of the scale. This does not include some generous allowances juniors are also entitled to.

Nearly all junior doctors work overtime - the average working week for a junior at the moment is around 54 hours. However, there are huge variations in both the level of overtime worked and the amount of overtime paid - some trainee doctors have to work around 70 to 100 hours per week.

One (presumably exhausted) junior doctor earned a massive €153,250 in overtime pay last year, according to the HSE.

If we can take it that this trainee doctor was already probably on a basic salary of around €60,000 plus, his or her annual income was over €200,000 - higher than the basic pay of many consultants working in the public sector.

This is an extreme case, but gives you some idea of how crazy the system is.

While the HSE has made some attempts to reduce the level of overtime worked by juniors , many trainees still work in excess of the set EU working time limit of 48 hours per week. The taxpayer paid out €165 million for trainee doctor overtime last year.

The average overtime payment per trainee doctor last year was €31,000. Therefore, a specialist registrar at the top of of the basic pay scale getting average overtime pay could earn €110,000.

Juniors here generally get higher basic pay than their equivalents in the UK, which is the most directly comparable healthcare system to ours.

A look at comparative pay scales shows that junior doctors in the UK generally earn between 10% and 30% less in basic pay than their Irish counterparts.

For example, a senior house officer (SHO) at the top of the scale earns €48,326 compared to €54,746 here - a 13% differential.

A specialist registrar at the higher end of the pay scale in the UK earns €58,323 compared to €76,062-€79,000 for similar grades in Ireland - a 30% plus differential.

Also, overtime payments for juniors in the UK are generally lower than in Ireland.

In the UK, trainee doctors get supplementary pay based on extra hours worked and the intensity of the work. The supplements are fixed in specific bands depending on the level of overtime. UK trainee doctors who do overtime receive an additional supplement, which would normally be between 20% and 50% of basic salary.

However, in Ireland there is a more open-ended and potentially spiralling overtime payment system for junior doctors. They get time and a half for all overtime worked after 39 hours from Monday to Friday, and double time on Sundays and public holidays, in addition to on-call payments where applicable.

A UK specialist registrar at the top of the basic scale getting an overtime allowance of 50% of salary would get a total of €87,484. In Ireland, a trainee at the same level getting average overtime pay would receive around €110,000.

The UK overtime system means that at the very upper end of the scale the maximum, total basic and overtime payment for a junior doctor can in a minority of cases can reach €116,000, whereas in Ireland, as mentioned before, basic and overtime pay for trainees in Ireland far more often exceeds €100,000 can in some cases can exceed €200,000.

Again, the key word here is 'trainee'. There can be no other profession that remunerates trainees, most of them in their mid- twenties to mid-thirties and still essentially learning their 'trade', at a rate that many graduates in other lines of work could only dream of enjoying in the latter stages of their careers.

Many reasonable people would feel the amount we are paying trainee medics is no longer sustainable in the current economic climate.

Another related issue that annoys many health consumers, and indeed annoys many doctors when you bring the subject up, is whether taxpayers always get a good deal from the huge amounts they pay out to train doctors.

Irish trainee doctors get an almost completely State-subsidised university education, and generous State-paid salaries while they are completing their training, yet there is no formal 'quid pro quo' for the taxpayer once they are fully-trained.

Many doctors pay us back by working in the public health system in Ireland. However, others go to work abroad or go into private practice. Having benefited from State-aided training, some trainees, once they are trained, give little back to the system and the taxpayer that helped train them.

When the Croke Park deal is being reviewed next year and the Government focuses again on how much we pay our public servants, three issues need to be looked at in relation to junior doctors:

* The amount we pay trainee doctors, in terms of basic pay and how overtime is calculated, needs to be cut to a more sustainable level, while still recognising their clinical skills and responsibilities.

* Some levels of overtime work by trainees may be necessary. However, excessive junior doctor overtime hours must be reduced by ensuring that we have more consultants on the ground and that we have a consultant-provided service as a result of the recent work practices agreement. It should be remembered that under EU law, no trainee should be working more than 48 hours per week. This is a safety issue more than anything else.

* Trainee doctor contracts, as is the case in other countries, should contain some type of 'payback' clause, under which all trainees are obliged to spend a certain amount of time in the State system treating public patients, once their training is over.

Trainee doctors will argue justifiably that they have already had income cuts, but then again so have vast swathes of people in the public and private sectors in our collapsed economy.

Ultimately, it matters little what doctors say they could earn if they left for Australia, Canada etc. There may well be some rich pickings in some other English-speaking medical systems outside the UK and Ireland, but the fact remains that our broke statelet can no no longer afford to fund medical mega-pay.

It can be argued that because doctors in this country have become used to generous pay while still in training, this has had a knock-on effect of fuelling inflated salary expectations once they are trained.

Thus, we now have the spectacle of trained hospital doctors doctors threatening to move abroad because they are 'only' to be paid around €120,000 for public work if they get a consultant post here, following the latest salary cuts.

The current debate in the medical community about earnings at present often seems slightly divorced from our current grim economic and social reality. But then again, nobody in any sphere, when it comes down to it, is going to admit that they are paid too much.

However, to put it bluntly, is it really fair, even taking into account the level of clinical responsibility a doctor has and for how long they have to train, that a young hospital medic should be earning two to three times or more what a nurse earns?

While recognising that we still need to pay doctors reasonable salaries given their level of responsibility and training, we need to cut our cloth according to our diminishing means.

And it's not just a question of not being able to afford to pay the pay bill. If we are serious about moving to a more socially cohesive society and an equitable health service, with a proper sense of public ownership and staff buy-in, we need a more level playing field in terms of healthcare earnings.




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