Diagnosing the Doctors??? Departure: Survey on Sources of
Dissatisfaction Among Irish Junior Doctors
1Cappagh National Orthopaedic Hospital, Finglas, Dublin 11
2Mater Misericordiae University Hospital, Eccles St, Dublin 7
3University College Hospital, Newcastle Rd, Galway
1, J Broderick
2, J Ong
3, J O???Byrne
There has been a significant decline in the number of applications for non-consultant hospital doctor (NCHD) posts in
Ireland over the last 18 months. We conducted an online, anonymous survey of Irish NCHDs to establish levels of
satisfaction, sources of dissatisfaction and the major reasons for junior doctors seeking work abroad. 522 NCHDs took
the survey, including 64 (12.3%) currently working outside of the Republic. 219 (45.8%) were slightly dissatisfied and
142 (29.7%) were extremely dissatisfied with practising medicine in Ireland. Major sources of dissatisfaction included
the state of the health care system, staffing cover for leave and illness, the dearth of consultant posts and the need
to move around Ireland. The most important reason for NCHDs wishing to leave was to seek better training and career
Many hospital departments are suffering NCHD shortages as increasing numbers of Irish junior doctors are electing to
work abroad, while fewer foreign doctors are seeking work in the Republic. The shortage is compounded by the phased
introduction of the European Working Time Directive (EWTD) that reduces the working week to an average of 48 hours,
meaning many more doctors are required to maintain the existing level of service. The shortfall has affected all
hospital specialities with emergency departments being worst hit. On 21st July 2011, the Health Service Executive
(HSE) revealed that there were 191 NCHD vacancies in Irish hospitals. Many reasons have been cited for the shortage.
Because of a lack of quantitative data, we conducted an online, anonymous survey of Irish NCHDs to establish levels of
satisfaction, sources of dissatisfaction and their relative importance, and the major reasons for these doctors
seeking work abroad. We also sought opinion from Irish-trained doctors currently working overseas.
49 HSE hospitals across Ireland were asked to bring the online, anonymous questionnaire to the attention of their
NCHDs. Respondents were asked to invite Irish-trained medical colleagues currently working abroad to take the survey.
Survey results were collected through an online, secure server between July 3rd and August 20th 2011. The survey
established the NCHDs??? demographics, nature of employment and intended specialisation, levels of satisfaction in
various aspects of their medical careers and average hours worked. Respondents were asked to rate the quality of
various aspects of their training. Non-Irish citizens were asked about unique difficulties they faced in Ireland.
Irish-based NCHDs were asked whether they were considering working abroad within the next 3 years and their reasons
for wanting to do so. Irish-trained doctors currently working abroad were asked which factors were most important in
their decision to leave Ireland. Finally, all NCHDs were invited to make general comments on issues covered in the
522 NCHDs took the survey. 458 (87.7%) were in Ireland, while 64 (12.3%) were working outside the Republic. 50.4% of
respondents were male. 162(31.0%) were specialist registrars, 130 (24.9%) were senior house officers, 122(23.4%) were
registrars, and 42(8.0%) were interns. Table 1 shows the breakdown according to area of intended specialisation. 74.9%
(n=391) of respondents were Irish citizens. Of the 131 non-Irish citizens, 34 were from the European Union, 19 from
Malaysia, 15 from Africa, 14 from Non-EU Europe, 13 from Pakistan, 9 from the USA, 7 from India and 20 from various
other countries. Of the 64 respondents currently working outside Ireland, 21 were working in Australia, 14 in Great
Britain, 12 in the U.S.A., 7 in Canada, 3 in Northern Ireland and 3 in New Zealand.
Levels of satisfaction
Half (49.9%, n=190) of respondents currently working fulltime in Irish hospitals were dissatisfied with their current
post (in terms of the general nature of the job and the quality of training they were receiving), with 15.4% (59)
extremely dissatisfied. Only 26.1% (100) were satisfied with practising medicine in Ireland in general, while 25.6%
(98) were extremely dissatisfied. Figure 1 shows how NCHDs currently working in Ireland rated their levels of
satisfaction for various aspects of their medical careers.
Hours worked and European Working Time Directive
For NCHD respondents currently working in Ireland, the average hours worked per week was 63.0. For Irish-trained
respondents currently working abroad, the average working week was 56.4 hours. Regarding the implementation of the
EWTD, 287 (75.5%) of the 380 Ireland-based respondents to this question indicated that it was not being enforced in
their current job. 230 (60.5%) were in favour of working under the EWTD, while 130 (34.2%) were not; 20 (5.3%)
responded that the EWTD was not applicable to them.
Figure 1: Levels of satisfaction for various aspects of doctors??? careers (n=458)
Diagnosing the Doctors??? Departure: Survey on Sources of Dissatisfaction Among Irish Junior Doctors1
285 (62.5%) of the respondents working in Ireland were considering working outside the Republic in the next 3 years.
Important factors for working abroad were better training and career opportunities (281), improved work-life balance
(223), easier path to consultancy (154), shorter training period to full qualification (n=138) and a desire for life
experience (109). 12.3% (64) of respondents were working outside the Republic. Figure 2 indicates the importance of
various factors in their decision to do so. 70.3% (45) of this group intended finishing their training abroad. 78.1%
(50) saw a shortage of consultant posts in Ireland as a reason not to return.
Figure 2: Importance of factors in the decision to work abroad (n=64)
Of the 131 non-Irish citizens, 29.0% (38) indicated that they experienced significant difficulties in obtaining
clearance to work in Ireland and for 55.0% (72) this played an important part in discouraging them from working in the
Republic. 85.5% (112) thought that being a non-Irish citizen made it significantly more difficult to get a specialist
training post in Ireland and 90.1% (118) thought that it made it significantly more difficult to become a consultant
or GP in Ireland.
All respondents not intending to do general practice were asked what they thought their chances were of getting a
consultant post one day in the Republic of Ireland. 48.3% (200) thought their chances were poor, 35.3% (146) thought
their chances were moderate, 13.0% (54) thought their chances were good, while 3.4% (14) thought their chances were
Figure 3: Ratings for various aspects of training (n=458)
Diagnosing the Doctors??? Departure: Survey on Sources of Dissatisfaction Among Irish Junior Doctors2
Quality of Training
Regarding the overall quality of NCHD training in Ireland, 42.2% (198) rated training as acceptable, 40.3% (189) as
poor, 15.4% (72) as good, while 2.1% (10) rated training as excellent. Figure 3 shows how NCHDs currently working in
Ireland rated various aspects of their training to date.
Despite the NCHD shortage gaining extensive media coverage, this is the first known national survey seeking the true
reasons from the NCHDs themselves. The sample size of 522 is admittedly small and results should be interpreted with
this caveat, given the potential for selection bias. The survey highlighted high levels of dissatisfaction amongst
Irish junior doctors. There are multiple sources of dissatisfaction; major factors included the state of the health
care system, staffing cover for leave and illness, the dearth of consultant posts, the need to move around Ireland,
the long hours worked and the degree of work-related stress. The perceived dearth of training and career opportunities
in Ireland emerged as the most important reason for Irish junior doctors heading abroad. 95.8% of respondents that had
left indicated that this was either an extremely important (74.5%) or important (21.3%) factor. Those currently
working in the Republic expressed a 95% dissatisfaction rate with the availability of consultant posts and a 65%
dissatisfaction rate with the availability of training posts.
The lack of a clearly defined pathway for NCHDs emerged as a source of considerable frustration. There are significant
bottlenecks for getting onto specialty training schemes and doctors may remain at junior levels for many years, having
to reapply for jobs every 6 to 12 months. With the substantial tax cuts and levies introduced during the recession,
and a clampdown on unrostered overtime, the financial incentives of working in Ireland are waning. 54.8% of NCHDs were
dissatisfied with their pay but only 32.6% of Irish-trained NCHDs currently abroad cited pay as an important factor
for their decision to move. So what has led to the current predicament, and what has been done to address it?
In April 1991, a collaborative group was established to analyse medical manpower in acute hospitals. Their discussion
document, published in June 1993 and known as the Tierney Report, highlighted the low number of consultant posts and
the mismatch between NCHD and consultant numbers, with a ratio of about 2 to 1
situation, having adverse implications for patient care, the efficient operation of hospital services and for the
training and career prospects of NCHDs. The ratio can be contrasted with that of the United States where the ratio of
residents in training to attending staff physicians is about 1 to 61. The collaborative group believed that there
needed to be a change from a consultant- led to a consultant-provided service for all patients. The report proposed a
target of 1,500 consultants and 1,500 NCHDs by the year 2003, but noted that this would require the adoption of
significantly changed work patterns by both consultants and NCHDs. The change would mean a 28% increase in consultants
and a 35% decrease in NCHDs.
1. This ratio was deemed an undesirable
The Comhairle na Ospidˆ'al increased consultant numbers to 1,558 by December 2000, surpassing the Tierney Report
target 3 years early
to each consultant was maintained. In the absence of a shift in policy, many of the problems in hospital medical
manpower identified in the Tierney Report remained. In June 2003, a National Task Force on Medical Staffing published
the Hanly report, which included a plan for reducing the working hours of NCHDs to meet the EWTD, as well as to move
to a consultant-provided service
posts - a ratio of 2.3. The average NCHD on-site working week in 2003 was 75 hours
the Hanly Report recommended substantially increasing consultant numbers while significantly reducing NCHD numbers,
and employing a team-based system with revised working patterns. They saw this as the only solution to simultaneously
improve patient care, reform medical training and provide high quality acute hospital care 24 hours per day.
2. However NCHD numbers grew at the same rate as that of consultants and the ratio of over 2 NCHDs
3. At that stage there were around 3,900 NCHDs and 1,731 hospital approved consultant
3. In line with the Tierney Report,
Since the Hanly Report, consultant numbers have continued to rise, reaching 2,446 at the end of 2010
there was a proportionate increase rather than a decrease in NCHD numbers. While there is now 1 consultant per 1,823
population compared to 1 per 3,000 in 1993, this ratio is half the 1994 EU average
emergency medicine, neurology, urology, and rheumatology are well below European averages for the number of
specialists per capita. Ireland???s 26 neurologists, 10 adult neurosurgeons and 4 paediatric neurosurgeons are the
lowest in Europe
hospital services and changing consultant work patterns has been hamstrung by the economic crisis. The HSE is
implementing almost ? 1 billion in budget cuts this year. The shortage of NCHDs is not related to funding or to the
recruitment embargo however, but due to the inability to attract sufficient doctors. As an ad hoc measure to counter
the current crisis, the HSE conducted a recruitment campaign in Pakistan and India, resulting in 270 doctors arriving
in Ireland in early July 2011. With long delays in clearing these doctors to work, there are concerns many will soon
4,5. However, again
6. Many speciality areas such as
5. While demand for service provision has continued to soar, plans at radically reorganising acute
The survey has shown high levels of dissatisfaction amongst NCHDs. In order to retain junior doctors in Ireland, they
must be provided with attractive training and career opportunities. As laid out by the Tierney Report almost 2
decades ago, a key part of the solution to establishing an efficient, well-trained medical workforce as well as a high
quality, cost-effective health care system lies in correcting Ireland???s inverted consultant to NCHD ratio and moving
to a consultant-provided service.
Sincere thanks to all the NCHDs who took the survey and provided valuable feedback.
Correspondence: R Bruce-Brand
Brookfield Lodge, 106 College Road, Cork
1. Collaborative group of the Department of Health, Comhairle na nOspidˆ'al, Postgraduate Medical and Dental Board.
Medical manpower in acute hospitals.1993 Jun. Available from: http://www.lenus.ie/hse/bitstream/10147/46291/1/1089.pdf
2. Comhairle na nOspidˆ'al. Eighth report of the Comhairle na nOspidˆ'al. 2000 Dec. Available from:
3. National Task Force on Medical Staffing. Report of the National Task Force on medical staffing. 2003 Jun. Available
Diagnosing the Doctors??? Departure: Survey on Sources of Dissatisfaction Among Irish Junior Doctors3
4. Comhairle na nOspidˆ'al. Ninth report of the Comhairle na nOspidˆ'al. 2005 Dec. Available from: Download full-text
5. Consultants Appointments Unit of the Health Service Executive. Consultant staffing statistics report. 2010 Dec.
Available from: http://www.hse.ie/eng/services/Publications/services/Hospitals/consultants2010.pdf
6. Jabubowski E, Busse R, Graham R. Health Care Systems in the EU ??? a comparative study. 1998 May. Available from:
Diagnosing the Doctors??? Departure: Survey on Sources of Dissatisfaction Among Irish Junior Doctors4