Long hours have been traditional but I become extraordinarily tired of those doctors in more senior positions who say "We worked those hours, why cannot those working in the medical field do the same?". That is ridiculous. Because a practice is bad now does not mean it was not bad then. Most junior doctors work in excess of 80 hours per week and some work more than 100. This is extraordinarily bad for them, as people, and we realise that the stress it has placed on them has caused a considerable number to leave medicine in the past number of years. Figures from the United Kingdom for the past decade show that between 10 per cent and 20 per cent of those involved in the medical profession leave within ten years of qualifying as doctors. I have spoken to numerous young doctors who, rather than working on the front line in the medical service, have gone into different fields. The hours are very hard, physically and mentally, and lead to alcohol and drug abuse. In fact, suicide has been the solution taken by a few people.
The position in the United Kingdom is better and it is a place to which doctors can easily emigrate. It is noticeable that the majority of interns in this country are Irish citizens but as one goes up the non-consultant hospital doctor pyramid one finds that between 50 and 60 per cent of senior house officers are Irish and while a certain proportion of registrars in the teaching hospitals in Dublin and the major centres like Galway, Cork and Limerick are Irish, yet outside these centres we depend totally on non-EU graduates - and when I say totally, I mean 100 per cent - to look after the Irish population.
The people working in Irish hospitals see a constant increase in the number of administrators in the health service and a decrease in those working at what I have described as the coal face. This leads to people feeling very unappreciated.
The increasing complexity of medicine, not to mention the increased level of litigation, means that every hour on duty is far more stressful than it used to be. Patients have higher expectations and these will not be met by exhausted doctors. Being on call and overworked frequently leads to more court cases. Patients and their families expect a great deal more and it is the junior hospital doctors who must deal with these expectations.
Training is not adequate in a large number of our hospitals outside the major teaching centres. Hospitals are having to rely on non-EU nationals but we now face the serious situation of the withdrawal by the Medical Council of accreditation for the education of non-EU doctors from some of these small hospitals. We will, therefore, have a smaller number of non-EU doctors coming here and we will be in an appalling position in a very short time. I have brought up the problem of non-EU doctors during several health debates. They are charged very large sums to come to do examinations and register here - the starting point is just £1,400 which is a lot of money for someone coming from a third world country who is coming to get further training. However, these doctors often end up in hospitals where the training is not accredited and we may lose them.
The Institute of Obstetricians and Gynaecologists is withdrawing accreditation for training of junior doctors from all maternity units with fewer than three consultants. The Minister of State knows that this means virtually all small units throughout the country. Patients are calling for small units to be kept open but we have a few one consultant and quite a few two consultant units and the withdrawal of recognition from these will mean that we have no units providing training throughout the country.
Many people think that non-consultant hospital doctors remain in the job for a year or two and then proceed to positions with large salaries. This is not so. In general, they are in these positions for seven to ten years and this has a serious effect on them. More than 50 per cent of medical school graduates are women and working conditions are even more difficult for women who, in general, take the greater burden of child care so that their progress in medicine if far more curtailed than it should be. This affects the promotion prospects of women doctors and impacts on family life.
Despite greatly improved pay and conditions in the United Kingdom, junior doctors there still refuse to agree to the remuneration bands put forward for them. They have better conditions than our doctors and I do not wish to see Ireland remain the only country in the European Union which refuses to bring in proper working conditions for non-consultant hospital doctors. I ask the Minister of State to urge the Department to address this matter before we get to the point of having people leaving Ireland immediately after graduation if they are Irish citizens, no non-EU nationals coming in because we cannot fulfil their expectations and a medical service bereft of those who do enormous work running it on a day to day basis.
Minister of State at the Department of Health and Children (Dr. Moffatt): I thank Senator Henry for giving me the opportunity to address this topic. It has been the subject of intermittent media comment in the past four months. Much of the media comment has been inaccurate or incomplete and I take this opportunity to set the record straight.
We appreciate the work of our young hospital doctors. They provide the bulk of front-line care in our hospitals and by and large they are the people you will meet in accident and emergency departments and on the wards at all hours of the day and seven days a week. They undertake the vast bulk of routine and no so routine medical tasks which are performed each day. If these competing demands are to be met properly it is important that junior hospital doctors' working hours are properly regulated. At present, these doctors' standard working week is 39 hours. Under their existing contracts they may be rostered for a maximum average of 65 hours per week. This is on average and it may be that in particular weeks the average may be exceeded. Equally, they may work less than 65 hours in a particular week.
It must be stressed that a junior doctor's working hours include periods spent on call. I will not contest claims that much on-call time is actually spent actively working. Equally, I have to point out that many NCHDs, especially more senior ones, spend much of their on-call duty at home. It must also be pointed out that existing rostering and payment systems do not make any allowances for the relative severity of on-call responsibilities. The same arrangements apply to doctors in relatively non-acute specialities as to those where doctors spend most of their duty hours on their feet. However, total weekly working hours are only part of the picture. Within an overall average which may seem reasonable, NCHDs may work long shifts of continuous duty with few opportunities for worthwhile rest periods. This needs to be looked at.
It is against this background that we must consider how the proposed EU directive on working time can be applied to Irish hospital doctors. People should be familiar with the background of the European legislation in this area as it was the subject of active discussion earlier this year. To recap briefly, NCHDs, as doctors in training, were excluded from the provisions of the original EU directive on working time adopted in 1993. They were just one of several groups which were excluded on the basis that the particular requirements of their sectors could not be accommodated within the framework of the generic directive. Other groups excluded were transport workers, offshore oil and gas workers and fishermen. Since 1993 the European Commission has worked with the excluded sectors to come up with a scheme which would offer a similar level of protection as the 1993 directive while taking account of the particular requirements of industries and services in which these groups worked.
The Commission published its proposals for these sectors in November 1998. They were examined by a working group under the aegis of the Labour and Social Affairs Council in the early months of this year. The Council adopted a common position on all of these groups in May and this is being considered at the European Parliament. In the case of NCHDs, attention has focused on the proposed 13 year transition period. Many consider this to be excessive and I agree with that. However, the European Commission, in its own proposals, has acknowledged that implementation of the 48 hour week for hospital doctors would require additional doctors to be trained. Typical undergraduate medical course are six to seven years in length but medical graduates are not considered to be fully trained doctors. All disciplines of medicine require a period of additional training before a doctor can be regarded as a fully trained specialist. These range from four to nine years depending on the speciality. While Ireland over-produces medical graduates it has been less successful in retaining post-graduate doctors, as Senator Henry explained. Many reasons for this are historical and the prevailing widely held view is that doctors should go abroad for training and experience. This is to be addressed with the introduction of new higher training programmes in medical specialities. I expect further reforms to flow from the work of the Forum of Medical Manpower. However, I emphasise that additional trained doctors cannot be produced overnight.
I again stress that Ireland is not opposed to a 48 hour working week for doctors. We want to introduce such a working week as soon as we can. However, this aspiration, if it is to be translated into fact, must meet two conditions. It must not prejudice patient care or adversely affect the career prospects of junior doctors by leading to a creation of large numbers of junior posts which offer no reasonable long-term career prospects. There is little point in injecting large numbers of additional doctors into existing careers and organised structures. A fundamental examination of how our doctors and, therefore, our hospitals work is needed.
As a first step agreement has been reached with the Irish Medical Organisation on a study of existing junior hospital doctor working hours. By mid-2000 we will have a report on the way forward and there is no doubt that the Senator will see what we will be proposing in regard to this issue. She should rest assured that we want to address it as soon as possible and a 48 hour week is the aspiration. Undoubtedly, more will be heard from junior hospital doctors encouraging us to bring it forward as quickly as possible. There is no resistance within the Department to facilitate junior doctors but a number of phases must be completed before we resolve the issue.
Dr. Henry: There may be no resistance but there is also no action. I will not rest assured because there will be more than nurses outside the gates of Leinster House and no one will work in our hospitals. I am dismayed by the reply.
Dr. Moffatt: To allay the Senator's fears, a steering group has been set up which will be chaired by Mr. David Hanly, deputy chairman of PARC and former chairman of Comhairle na nOispidéal. It should have completed its work by mid-2000 and it will come up with the goods then. We take the Senator's remarks on board and an initiative on the issue is in place.
Dr. Henry: I thank the Minister of State but I will raise this again.
