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THE MORNING LEAD

'Bonkers' overtime worked by junior doctors causing burnout and risks for patients

Junior doctors in Ireland worked 2.8 million recorded overtime hours last year, according to figures from the HSE.

EXCESSIVE OVERTIME WORKED by junior doctors is causing burnout and unsafe working conditions, doctors say.

Junior doctors are regularly working hours far beyond what should be acceptable in Irish hospitals, doctors have told The Journal, to the detriment of patients and staff.

Non-consultant hospital doctors (NCHDs), or junior doctors, are doctors working in hospitals who are not consultants but who provide important medical care to patients and are often taking postgraduate training in a particular specialty.

In 2021, junior doctors in Ireland worked a total of 2.8 million recorded overtime hours, according to figures from the HSE.

On average, between 2016 and 2021, they worked a collective 2.5 million hours beyond their contracted time.

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Dr John Cannon, the chair of the Irish Medical Organisation’s NCHD committee, says the level of overtime worked “proves how bad the conditions are for junior doctors”.

New figures released under the Freedom of Information Act, first reported by the Irish Independent at the weekend and obtained by The Journal, say that the 25 highest overtime amounts paid to NCHDs last year ranged from €91,213 to €169,772. In several cases, the amount of overtime exceeded their basic pay.

Eight of those junior doctors were based in Galway, four in Cork, and three in Limerick. There were two each in Laois, Sligo, and Wexford, and one in Donegal, Kilkenny, Kerry and Louth.

Speaking to The Journal, Dr Cannon said the figures are “essentially an admission of guilt by the HSE and Department of Health as to the dangerous and illegal working time hours that junior doctors are doing”.

“The only way that those junior doctors could have received those overtime payments is if they were working absolutely insane and dangerous hours,” Dr Cannon said.

“Even if you generously apply a high overtime rate in order to make the number of hours low, those doctors would have had to work – on top of their 39-hour basic week – an additional 40 or 50 hours a week every week for the entire 52 weeks of the year to reach those numbers, which is absolutely bonkers.”

“I think the public can put two and two together. They see what’s happening and they have been incredibly supportive so far because they do not want their mother, their father, their brother or sister to go into an Irish hospital and their care to come under an exhausted doctor,” he said. 

Hospital doctors work overtime hours to cover short-term staff absences and to alleviate immediate service pressures, according to the HSE.

The IMO has launched a campaign called #StandingUp4NCHDs that is calling for better working conditions for junior doctors.

A survey by the IMO heard that 96% of NCHDs have been required to work more than 48 hours a week, 40% have been required to work more than 24 hours in one shift, and many reported routinely not being paid for all the hours they worked.

A lack of suitable rest breaks and on-call facilities were raised as significant problems, while 91% said they had difficulties availing of study leave and 50% had difficulties taking annual leave.

On social media, junior doctors have shared stories about how working long hours without reprieve has affected them, including car collisions that happened when they were exhausted while driving home.

Speaking to The Journal, Dr Shubhangi Karmakar, an Academic Intern and Advanced Diploma in Medical Law candidate, described the heavy burdens placed on junior doctors.

“From experiences around the country, no one seems unfamiliar to 6am texts when you’re unwell to ask if you’ve arranged cover, indirect ‘chats’ to suggest protection of educational time doesn’t apply to overtime ‘obligations’, or even being asked if one is sure one can’t make time to come in during annual leave,” Dr Karmakar said.

“That can become scary – because while pressures arising in the HSE are rarely communicated formally, disciplining for implied ‘obligations’ is always taken down a formal route – leaving NCHDs unable to collect a coherent ‘paper trail’ if they need to defend themselves,” they said.

“Equally, though, there arises the question of how NCHDs think about practicing within our responsibilities, but also our rights – and I think very limited induction in legal and regulation literacy feeds into that too.

“We have a right as professionals, to do our best work every day, and poor working conditions are an unacceptable obstacle to that.

There is sometimes so much overwork that instead of aiming for the best and safest care for our patients and landing somewhere in ‘good care’, the goalpost moves to normalising ‘covering the bare minimum’.

“This vastly increases the risk of doctors either practicing pre-emptively defensive medicine, or falling short of minimum standards – both leading to care mismanagement.”

Covid-19 impact

In a statement accompanying the figures released under FOI, the HSE attributed the high levels of overtime pay in part to the Covid-19 pandemic.

It outlined that increased Covid-related staff absences and the demand on the health service had a significant impact on overtime hours.

In mental health services, where the availability of staff was already below demand, partly linked to emigration, vacancies in medical and nursing positions were compounded by the pandemic, it said.

Speaking to The Journal, Sinn Féin TD and health spokesperson David Cullinane said the problem of junior doctors working extensive overtime “existed long before the pandemic”.

“For a long, long number of years… we’ve had issues with junior doctors working long hours, breaches of the European Working Time Directive, and issues in relation to what actually constitutes overtime in the mix of working hours versus training hours,” Cullinane said.

The European Working Time Directive is legislation that says employers must ensure staff do not work more than 48 hours in a week on average, including overtime.

Employees must be given at least 11 consecutive hours of daily rest and 24 hours of rest every seven days.

Cullinane described it as “really problematic” that many junior doctors are compelled to work overtime on top of their training and work hours “simply to pay the bills”.

“It’s on the one hand their training hours and then it’s the hours that they spend on service provision or working formally in the healthcare system, and that obviously puts pressure on the doctor who’s working very long hours, but it also puts patients at risk, potentially, as well,” he said.

“It’s not a good working environment and it’s one of the reasons why we see hundreds of doctors emigrating every year to Australia, Canada, America and elsewhere. Partly they go because they can see better opportunities to train and upskill, but also it’s because of the long hours.”

Similarly, Dr Karmakar said that issues with working and management culture “transcend ‘Covid times’”.

They said that “one common reason for mounting overtime requirements, for example, is ‘staffing pressures’.

The issue is, even when adequate NCHDs are rostered, a lot of overtime work is undertaken by doctors having to overstay shifts to reduce task burden on handovers.

“Everyone is pushing towards burnout, as service demands constantly push us to tweak or overreach scopes of practice, and we continue to support overworking ourselves because we never want our colleagues to feel how we do after a set of rough days or nights.”

The IMO survey found that 78% of junior doctors feel they are at a high risk of burnout.

Additionally, 70% are dissatisfied with their work-life balance and 91% feel they have little or no control over their work life.

‘We feel like an export commodity’

It’s understood that Minister for Higher Education Simon Harris is expected to soon bring a proposal to Cabinet to create an additional 200 places on medicine courses by 2025.

Currently, across Ireland’s colleges, around 750 students are accepted to undergraduate medicine courses each year; some of the most sought-after higher education places in the country.

“Increasing capacity and having more junior doctors and taking pressure off would certainly help,” Sinn Féin’s David Cullinane said.

“We need to look at the training model to ensure that we don’t have doctors that are doing very long training hours on the one hand and service provision hours on the other because that’s a problem.

“We also need to look at the other supports as well. I think you have to look at what’s happening in the hospitals and what support staff are in place to support junior doctors. We know that there are some hospitals with a shortage of nurses, but also physiotherapists and radiographers – if those staff are not there, it puts additional pressure on doctors as well.”

On the ground, Dr Cannon and Dr Karmakar say that working long overtime shifts cannot continue to be a normal expectation of junior doctors.

“We need to have a system with enough redundancy that doctors can routinely work European Working Time Directive-compliant hours and that the absolute exception, the outlier, is when a doctor becomes non-compliant and works over 48 hours a week,” Dr Cannon said.

“The problem is that that is not the exception at the moment, that is the normality. It is the expectation of doctors that they will routinely work 9, 10, 11, 12-hour days and work 60, 70, 80-hour weeks.

We now need to get to a point where we have enough doctors so that doctors can actually go home at a reasonable hour.

“That doesn’t fix all the problems, but it takes pressure off those young parents that aren’t seeing their children, the doctors that aren’t seeing their family or friends – and that are unable to cook for themselves, and eat healthily, and exercise and do all the other physical and mental extracurriculars that create a healthy work-life balance.”

Dr Karmakar pointed out that additional medicine places created at third-level will need to translate to the hiring of more interns to have any meaningful impact.

They said it is no surprise Ireland struggles to hire back junior doctors who have worked abroad in more supportive environments and that there should not be a need for social movements to plead to the government to hire newly-qualified Irish doctors.

“When we talk about a ‘no blame’ culture, that means #StandingUpForNCHDs needs to get us talking about our experiences around the country, and our systems and the public need to understand these conversations happen in good faith,” Dr Karmakar said.

“None of us enjoy sharing our experiences as doctors – and that’s so sad for what is some of the most rewarding work in our lives – and truly, if we were acting out of individual gain alone, people probably wouldn’t bother sharing to change the system.

They’d do what doctors are currently doing in droves – they’d ‘keep the head down until they get out’; leave the HSE and the country.

“By sharing our experiences and advocating for industrial action – we’re trying to be uncompromising not with our ‘self-interests’ or ‘petty slights’, but with the best interests of Ireland’s patients, and also our peers, Ireland’s doctors.

“NCHDs should be a valuable asset to Ireland – we train in some of the most intense working pressures of any equivalent training level in any other jurisdiction. But right now, we feel more like an export commodity lost at sea, trying to find any shore to tether ourselves because we can’t stay home.”

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