Report of the Pay Commission on Recruitment and Retention
The report on the Pay Commission on Recruitment and Retention1 under the chairmanship of Kevin Duffy was published on 31st August 2018. The Commission was established to advise Government on public service remuneration policy. Its task was to determine whether there is a difficulty in terms and recruitment, and where present, to examine the causal factors. The groups with these difficulties ie nurses and doctors, are identified. The Report accepts that the future demands for healthcare will increase the demands for more doctors and nurses.
The Report states that the causes of recruitment and retention problems are multifactorial. The Commission invited submissions and met with stakeholders. It sought data on recruitment and transactions and departures. It stated that poor tracking of relevant data constrained the capacity to make definite evidence based conclusions.
The Report has concluded that, notwithstanding some of the specific non-competitive findings, current pay rates do not appear to be unduly affecting the number of nurses and doctors applying to work abroad. Its stance is that remuneration is not the main issue impacting on recruitment and retention where difficulties exist. It is of the opinion that training and promotion opportunities are the key influencers of migration and turnover in NCHDs. In relation to difficulties in consultant recruitment, it accepts that certain specialties and locations are unduly affected. It concurs that the appointment of consultants not on the Specialist Division of the Register of Medical Practitioners is a strong indication of the challenges facing the healthcare services.
The Report runs to 140 pages over 9 chapters. The chapter on NCHDs states that their total number in 2017 was 6,331. They make up 6% of the health service, and play an important part in the delivery of health care. The 2 main sources of supply of NCHDs are the medical schools and international recruitment.
Fifty eight per cent of the NCHD workforce is of Irish nationality. The remaining 42% of posts are filled by overseas graduates.
The IMO submitted a document stating that 10% of doctors aged 25 – 34 years are leaving the Irish Medical Register, most likely for posts abroad. In the case of Interns, 45% of this group were no longer working in the public health service and had emigrated. The IMO further emphasised that retention had never been more challenging. The important causal factors are discontent with training and supervision, the removal of the training grant, long hours and on-compliance with EWTD, and the poor comparison with international pay rates.
The Commission’s conclusion differs. Its opinion is that training and promotion opportunities are the key issues. It states that the new entrant SHO salary is 7% higher than the UK, 8% lower than Canada, 12% lower than Australia, and 19% lower than the US. Based on this data it concluded that the remuneration is satisfactory.
These superficial comparisons are over-simplistic. When one speaks to NCHDs on the ground the reality is different. The first year SHO has a salary €43,662.32. The stoppages consisting of USC, PRSI, Pension, Pension Levy and Income Tax amount to at least 40%. The take home pay is €26,197.20. The SHOs annual mandatory educational and professional outgoings are substantial and have to be paid out of her salary. They are as follows, Medical Council Registration €630.00, MPS/MDU €1000.00, APLS course €750.00. The post-graduate exams are in 3 parts costing €600, €650 and €700 respectively, the total being €1950.00. Only €1350.00 of these exam fees are refundable and repeat attempts are not paid. Many trainees have to repeat at least one section of the examination again. Textbooks cost at least another €300.00. The registration fee and travel expenses for national and international meeting is not funded. The total professional/educational outgoings amount to at least €3000.00 per year, which reduces the take home basic salary to €23,972.0. The NCHD’s only other source of income is overtime payments which is very variable.
An additional problem relates to the NCHD 6-month rotation from hospital to hospital. At the commencement of every rotation the new hospital’s salaries department places the NCHD on emergency tax until the P45 arrives from the previous hospital. This can take up to 3 months. In a 2-year rotation the NCHD will be on emergency tax for 8 months or more. This problem was exacerbated when hospitals changed the start date of rotations. Rotations now start on the second week of July and January in order to suit the hospitals which means that the NCHD is being paid part of his salary by 2 hospitals during those months which adds to the tax confusion.
Many NCHDs have stated that they have difficulty paying their rent during these months of emergency tax imposition. This problem was raised in the MacCreath report 5 years ago but nothing has changed. NCHDs perceive the lack of action on this issue exemplifies their employers disinterest in their welfare. In Australia when NCHDs change hospitals, their tax credits follow seamlessly from one hospital to the next.
While this current Commission did receive submissions from representative groups, it doesn’t appear to have met with individual NCHDs. This is a deficit. The Report has not got to grips with the reality of being an Irish trainee and the financial challenges that they face. Training is very expensive and places a considerable financial burden on the trainee’s already modest final salary. An additional pressure is that many of the NCHDs are postgraduate entrants and have university loans to pay off.
The experience encountered by a first year SHO in the workplace greatly influences his present opinion and future attitudes towards the Irish health service. The take home salary, the heavy workload, the exams, and the high personal costs of training are factors that will influence his decision to look elsewhere for work. This cost of training is a significant financial imposition on a trainee and unless it confronted recruitment and retention will continue to be a problem. In Australia all expenses associated postgraduate training and education are paid for. The negative attitudes of doctors towards a health service are set early on in their career. When trainees become disillusioned they either leave hospital medicine or emigrate.
The Commission recognizes that there are difficulties in consultant recruitment. One in four of the posts advertised in 2016 by PAS failed to attract any suitable candidate. The low levels of applications for advertised permanent posts restrict the calibre of candidate choice available employers. The Commission interpreted these data as indicative of a significant on-going problem in regard to recruitment of consultants. The main recruitment themes that emerged were certain specialties and locations, the two-tier pay system, shrinkage in the number of applicants, and the recruitment process. The consultant turnover rate is 6.6% excluding retirements. The Commission concluded that this turnover rate is not excessive.
There is recognition, however, that the reductions in pay applied to consultants appointed since 2012 were particularly severe and greater than those in other categories of the public services. The settlement of the 2008 consultant contract claim will exacerbate the difficulty. The Commission proposes that parties to the public service stability agreement should consider what further measures could be taken over time to address this difficulty.
It states that the current recruitment process for consultants is not functioning effectively. There are delays at a number of stages in the process.
There is a problem with the recruitment and retention of doctors in Ireland. Retention is the major problem in relation to NCHDs and recruitment is the issue in relation to consultants. The problems are exacerbated by the international competition for highly skilled specialists. The Irish health care service must be competitive in order to be able to deliver high quality medical care. Things go wrong at an early stage in a trainee’s career. More needs to be invested in NCHD training and the personal financial burden associated with postgraduate training should be removed.
The discrepancy in consultant salaries pre and post 2012 has to be addressed. Whenever prospective applicants apply for a consultant post, it is one of the first items that they raise when they visit the prospective hospital.
The pay commission report has opened the debate. The next steps are the provision of realistic solutions.
1. Report of the Public Service Pay Commission. Recruitment and Retention Module 1. August 2018.