Junior doctors are set to take industrial action next month in a bid to force the HSE to implement a maximum working week of 48 hours, which is a legal requirement under the EU European Working Time Directive (EWTD)
The IMO says it wants an end to junior doctors, or non-consultant hospital doctors (NCHDs), having to work in excess of 70 hour per week and on continuous 36-hour shifts, which, it says is bad for doctor's health and unsafe for patients.
So, with the IMO indicating that the action taken may involve all-out strike action which would cause major hospital disruption, we asked IMO junior doctor chairman Dr John Donnellan why things have got to this stage and what it will take to resolve the dispute.
The industrial action proposed is 'up to and including strike action'. If all-out strike action is taken, is it likely that junior doctors will withdraw from providing everything bar emergency cover in hospitals?
After the ballot result is known on September 2, the IMO NCHD committee will decide on the following day what format of industrial action we are prepared to take and what is going to be safest and fairest for patients. At the same time it has to be something that has to strike a meaningful, resonant note with HSE management. They have had 10 years to get the working hours issue sorted out. Whatever we do will have to impact management but at the same time we don't want to do anything that is going to affect patient care, and definitely not emergency services.
Do you think feelings are such that the IMO will decide the action to be taken should be strike action?
It goes against your training and your mindset as a doctor to go on all-out strike. But NCHD, are completely fed up. In what little engagement there has been with HSE management on this issue, no solution has been offered to the working hours issue. The reason we are balloting on industrial action is to force our employers to undertake what is a legal requirement of them anyway. So, yes the appetite is there at the moment to do something that will strike a chord with management and get them to sit down and listen to us.
If it does come down to an all-out strike, will emergency cover levels be an issue, as it has proved to be during previous nurse and junior doctor strikes?
Yes, that would obviously have to be taken into account. The last thing any junior doctor wants to do is to affect emergency care for patients or care for the critically unwell in hospitals. Any action we take will have to be very cognisant of the fact that we do have an ethical and moral responsibility to our patients which has to be protected.
What is the current average working week for junior doctors?
The HSE so far hasn't able to provide us, or indeed anybody thus far, with precise figures on average working hours. The reason for this is that they have an archaic system for recording hours in the hospitals where they do this and in some hospitals they don't even record hours. In hospitals where there is an electronic clocking system, there is a slightly more accurate representation of the hours that NCHDs work. I would say the average junior doctor works definitely in excess of 60 hours a week. Some work more than 70; some even work more than a 100 hours per week.
How common is it for some NCHDs to work 36-hour continuous shifts?
I would say the majority of NCHDs work at least 36 hour shifts. In any hospital that operates a 24 call system, the doctors there would work at least 36 hours at a time, and that would be in practically every hospital in the country. Each week, an NCHD could be on two or even three of these long shifts. There are some surgical registrars in smaller peripheral hospitals who are on one in two or one in three rotas, where every third day they would be on a 36-hour shift. There is a 12-hour shiftwork system in place in, I think, two hospitals in the country is as very recent innovation. University Hospital in Galway implemented that shiftwork system five years ago. There is a binding legal requirement, it should be pointed out, to have a 12-hour maximum shift, but it's not implemented in most hospitals.
When someone is working a 36-hour shift what proportion of that time would they be ‘on the floor' on active duty, and what proportion would they be ‘on-call' but not actively working?
I would say that of the specialties that engage in the 24-hour call system, NCHDs working under those systems would be on their feet for the 36 hours. If they are very lucky they may get an hour or two hours to lie down in the middle of the night, but that would be the extent of any rest that they get.
Are there specific examples/incidences of where patient safety has been compromised due to over-tired doctors treating them?
The IMO has been trying to raise public awareness in terms of these potential adverse outcomes. NCHDs in recent weeks have been taking to the airwaves with their own personal experiences. Because it is such a personal thing for most doctors, it is very difficult for some people to feel like they should own up to all of this. You are talking about potential medication errors, that sort of thing. After 36 hours on your feet, awake, doing strenuous mental as well as physical work, it's a struggle to keep your eyes open, and at the same time you are still expected to place tiny 21 or 22 gauge needles into people's veins, you are expected to still be sharp with drug calculations... I don't think anyone can be naïve enough to think you would be as sharp on your 36th hour as you would have been four hours into your shift.
It has been said that more Irish doctors than ever before are emigrating or planning to emigrate because of poor working conditions/pay etc. Are there any statistics to back this up, given that traditionally, many young Irish doctors have gone abroad to train?
Well, the IMO recently surveyed NCHDs, which showed that 800 junior doctors were planning to leave the country this summer. If you ask any doctor you will see that they have classmates, friends, family who are all emigrating, working in other countries. The problem is, previously these doctors might have gone abroad, but the plan was always to come back to Ireland eventually. But now, those doctors that are leaving are not planning on coming home.
What's the solution to this dispute - what could the HSE do tomorrow to resolve it? Would a resolution require employing more doctors, for which the money probably isn't there at the moment?
In terms of the hours and in terms of any planned industrial action, the first thing the HSE has to do is to step up to the base in terms of its legal requirement in terms of maximum working hours for junior doctors. The '24 no more campaign' being run by the IMO is campaigning for a shift-length maximum of 24 hours, which in its own right, by the way, would still be outside the requirements of the European Working Time Directive, which stipulates a 12-hour maximum shift.
But on a practical level what could the HSE start doing right away to achieve that limit on shift work?
It all has to do with more efficient work practices. In some hospitals, for example UHG, and the Mercy In Cork, they have implemented smarter working patterns, shift-based systems etc whereby they just make better use of their NCHDs. Employing more doctors might in some specific cases be required, but for the majority of hospitals, getting down to a 24 hour shift maximum is simply a matter of smart, intelligent rostering.
In terms of extra doctors, surely it's not feasible to have twice as many NCHDs as consultants, and this balance essentially needs to be reversed to have a proper consultant-provided service, with less reliance on junior doctors and on huge levels of overtime?
The number of doctors provided, whether it is consultant-led or consultant- delivered, or whether it NCHD-heavy or consultant-heavy, isn't going to change things immediately. If you have a rota whereby you have only got two doctors supplying an on-call service, obviously those doctors will never have a 48-hour maximum working week, as there aren't enough doctors to go around. In that type of scenario, obviously extra doctors are needed. However, I still firmly believe that in the majority of cases, it is smarter rostering that is required.
But surely, the ideal situation is to have a service provided by consultants on the ground, with more senior decision-making, rather then consultants directing a service what is largely provided by junior doctors?
Yes, it is the junior doctors who are providing the day-to-day service of most of the hospitals. They are backed up by their consultant colleagues-they are always available to you for advice and assistance . But a consultant-delivered service doesn't appear to be practicable at present in the current economic climate. You are not going to be able to go out tomorrow morning and employ 300 new consultants. The Minister and the HSE are not filling current consultant contracts. There are over 100 posts advertised of which they have filled less than half. It should be pointedout that what doctors are beingoffered now, What they are offering doctors now, not just the salaries, which have taken a disproportionate hit, bit the terms and conditions, are now much worse than what a doctor can get in any other English-speaking country.
But are Irish junior doctors not still, despite significant recent cuts, still relatively better paid than in other countries?
No, the basic pay of junior doctors in Ireland are at the lowest rates among all other English-speaking countries. If you include overtime pay, our earnings may be higher in some cases than our UK counterparts, but generally, our pay rates do not compare well internationally any more.
The HSE spends a huge amount of money on NCHD overtime. Do you believe the current system is not only inefficient and unfair, but also too expensive?
The simple fact is, if you were to bring in the EWTD for NCHDs and limit their hours to 48 per week, instead of 70 per week, you are automatically shaving a huge proportion of the overtime bill. We are asking for a reduction in hours in the knowledge that it is going to mean that our take home pay is less. But this would provide a safer patient service. And you would not have to employ extra doctors to compensate for the shorter hours. IN UHG, for example, they rostered people for day shift and they rostered people for night shift, so during the day, you have slightly fewer doctors on the ground and at night you have normal night cover - this didn't increase the overall overtime bill at the hospital. In fact, it would have reduced it, because instead of all doctors staying on until 7-9pm finishing off individual jobs, and thereby adding to overtime costs, you have a specific day shift and night shift pattern, which people can alternate between.
Would most junior doctors gladly trade lower earnings for fewer working hours?
Absolutely, and this campaign is based on the knowledge that a reduction in hours will mean our take-home pay is less, but we would no longer be doing the crazy overtime hours we have been doing.
But don't many junior doctors rely on the extra money they would earn through overtime, however arduous that might be, given that they would be at a stage of their lives when they are buying houses, starting families, paying off student loans etc?
Well, at the moment a lot of them would be saving for plane tickets to Australia and New Zealand. Obviously, everyone relies on their pay packet to pay the mortgage etc, but what is at the core of this campaign, ultimately, is patient safety. If our hours are reduced, we will obviously be taking a reduction in pay but we would have better, safer conditions for our patients and safer working practices for NCHDs.
If the solution to this dispute simply requires better rostering in hospitals, and not necessarily taking on extra doctors, why has so little progress made on this that NCHDs feel they have to strike to force change?
For the majority of hospitals, all it requires is a bit of intelligent rostering to make the 24-hour shift system we want to actually happen. This issue has been frustrating junior doctors for years. We were barred from taking industrial action over the past two years while in return, the HSE said it would get the maximum 48-hour week in place. But they have done nothing about it and they did nothing for eight years before that.
All out doc strike now likely
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