‘There is a huge amount of trauma across the NCHD population’

Chair of the IMO NCHD committee, Dr Rachel McNamara, speaks to Catherine Reilly about some of the issues that must be addressed in a new NCHD contract

Dr Rachel McNamara has taken the helm of the IMO NCHD committee as the Organisation prepares to enter negotiations on a new NCHD contract. She has succeeded Dr John Cannon, who led last year’s ‘Standing up for NCHDs’ campaign on excessive and illegal working hours, among other issues. In June 2022, NCHD members voted overwhelmingly in support of industrial action before endorsing an agreement reached with healthcare management late last year.

“John did an excellent job last year leading us through quite a high profile and ultimately highly regarded campaign,” Dr McNamara told the Medical Independent (MI).

“On foot of that, we entered negotiations around urgent contract breaches and issues surrounding those with the Department and HSE at the end of last year, and ultimately reached a successful agreement on those issues in December 2022.

“I have come into the role at a really exciting, but I suppose somewhat daunting, time, in that we are soon to enter negotiations on the new NCHD contract, and that was agreed in the context of the December 2022 agreement,” outlined Dr McNamara, a SpR in public health medicine.

These negotiations will have to be traversed in parallel to pushing for full implementation of the 2022 agreement, which included new contractual terms relating to rostering and compensatory rest. The IMO has been dissatisfied with the level of implementation in some sites to date, confirmed the NCHD Chair.

Future proofing

The current NCHD contract dates to 2010 and Dr McNamara noted that a new contract will need to serve NCHDs now and into the future.

“The contract has to protect the NCHD in terms of the potential changes that we will see in the role over time, but also serve to attract and retain NCHDs into the role in the context of a worldwide healthcare worker crisis,” she said.

Dr McNamara is the first female Chair of the NCHD committee, which she acknowledged as “long overdue” (she added that the IMO has had female chairpersons of other specialty committees; it has also had female Presidents).

“But in that sense, I really do want to highlight and champion issues that chiefly, to date, have affected women most particularly, but do affect all NCHDs in a lot of cases.

“Pieces around flexible working options, ability to access leave, ability for doctors who are carers or who are parents to be able to work sustainably and effectively in their roles and achieve some degree of work/life balance. I would see that as a huge priority as well.”

Diversity

The IMO NCHD committee includes Irish and international doctors representing a range of specialties and experience levels. This composition is important in informing the committee’s positions in negotiations, according to its Chair.

In advance of the contract talks, Dr McNamara identified a number of important areas such as the financial burden of training and the impact of rotations on NCHDs’ lives. The current structures are restricting many NCHDs from being able to put down roots and have a personal life, she said.

“We are looking at ways that we can try to protect NCHDs’ rights to have a family and forge relationships and have a life, while still being able to progress in their training.”

Some of the “hardest stories” she has heard during her time on the NCHD committee have related to rotational requirements. The issues raised have included financial distress, prolonged separation from family, and lack of crèche/childcare support.

“There are a number of ways to address this, but it has to be seriously re-examined… people are just not going to do that anymore,” said Dr McNamara. “I have known a good number of NCHDs who have left schemes because the sacrifice has been too great; they are not going to get those years back with their family.”

Dr McNamara said there are “ambitious plans” to increase the consultant workforce. However, “we will never get there if people continue to be forced to make these impossible choices to leave their families, or pay two rents when rent is so colossal, potentially on top of fees for graduate-entry medicine.”

Under the 2022 agreement, the Department of Health and HSE acknowledged the financial burden for trainees who must rent a second residence during rotations. They committed to agreeing measures to address this issue as a priority. However, Dr McNamara confirmed this matter had not yet been resolved. She underlined that in many other sectors, where an employee was required to move location for work purposes, these expenses were covered by the employer. 

Dr McNamara said the Organisation was also examining ways in which a new contract could help facilitate greater access to flexible working for NCHDs. She said it was vital to support doctors to work in a “sustainable manner”.

“Ultimately, if you have more people working in a sustainable manner you are going to have a more satisfied and fulfilled workforce; you are going to retain doctors, you are going to bring people back.”

The barriers to training access and career development for international doctors is another area being explored.  “There are, we believe, additional protections or additional elements that can be set down in the contract to make
that process easier and to remove barriers to equity of access, to progression,” she said.

Additionally, Dr McNamara said the new contract must be relevant to NCHDs outside the hospital system, who sometimes face “certain distinct challenges”.

MI asked Dr McNamara if there were examples of practices from other jurisdictions that she would like to see discussed during the negotiations.

She referred to protocols relating to back-up rostering that are operational in some Australian centres. “So that [in] a situation where a doctor is unavailable to present for work, there is somebody automatically there to fill that role in that instance.”

“Even though that model has its problems, in that there is a perception that it would promote absenteeism, I think what I would like to see are additional protections for doctors on-call and also for patients in times where they are covered by on-call services; that there would never be an instance where the absence of a doctor on site could either place an unacceptable burden on the remaining staff and also create a risk scenario for patients.”

She confirmed that the issue of additional protections for NCHDs on-call was being examined by the committee in the context of upcoming negotiations.

“If there is an unexpected absence and an on-call position is not filled, it is just bad for everyone from patients to hospital management to the NCHDs remaining on the floor. So those sorts of protections to be built in would be another priority area. But as to how best to do that is up for discussion.”

2022 agreement

The Organisation is facing a battle to get the terms of the 2022 agreement fully implemented. The deal covered issues that were considered the most urgent among the NCHD membership. The agreement was described by the IMO as a starting point to comprehensive reform of NCHD working conditions, which ultimately required a “fit-for-purpose” new contract. In December, some 81 per cent of NCHD members voted to accept the terms.

The agreement included a defined set of rostering rules, which were incorporated into the existing NCHD contract. These rules were aimed at ensuring NCHDs have adequate rest periods and at least every second weekend off duty; limit the number of consecutive days that can be worked; financially penalise the employer where rest is not granted; and compensate the individual NCHD where rest is not granted.

If an NCHD is rostered to work 10 days in a row, they are entitled to be rostered off for one day; or where an NCHD is rostered for 11 days straight, they are to be rostered off for two days. This rest must be rostered after the period of consecutive days.

If the NCHD does not get to take this rest, either by being called in or due to shortages, this rest becomes ‘compensatory’ rest. The employer must roster this within the following four weeks over and above the normal rest the NCHD is due for that period. If they cannot roster this additional rest, the NCHD is entitled to be paid for these days in the following pay period.

These rules also place a limit on the number of long shifts and 24-hour  shifts. In any two-week period, the NCHD should not be rostered for more than two 24-hour shifts; four 13-hour shifts; and any combination of 13- and 24-hour shifts cannot exceed 96 hours.

There is provision for a third 24-hour shift, in exceptional circumstances, but if so then an extra compensatory rest day is required to be provided.

The agreement also included a commitment to a new working hours verification system (which is still awaited), and for all NCHDs to be on a single payroll system by the end of 2023. Enhanced training supports and guaranteed study leave for gateway/mandatory exams were among the other features of the agreement.

Dr McNamara said some of the measures, such as those relating to the
training support scheme, were implemented quickly. 

While it had been anticipated that certain reforms would require a “lead-in time”, there is concern about the level of implementation to date.

“As recently as last week, reports have come through from a site that hadn’t heard of one of the elements of the agreement…,” stated Dr McNamara, who spoke to MI shortly before the July changeover. “It doesn’t instil huge confidence in it being rolled out in the way we would hope, because every part of that December 2022 agreement with regard to the rostering rules and changes around compensatory rest, are now contractual agreements…. When you hear six months in, some sites are not aware of it, then it does raise concern.”

“When it comes to the compensatory rest days and rostering rules, it has been very hit and miss from the reports,” according to Dr McNamara. She noted there have been legacy rosters in place and suggested the period following the July changeover would be telling.

  She emphasised that if there are not enough staff to complete the rosters, human resources or medical manpower “need to recruit into it”.

“I think there is agreement across the board we need more doctors on the floor… this is a way to make sure that those sort of staffing shortages are addressed and can be decided looking at the roster. Can it be staffed without breaking any of these rules and if it can’t, there needs to be active and urgent recruitment.”

The union has been gathering data on implementation of the agreement and will continue pushing for full enactment, according to Dr McNamara. She said it was in the health service’s best interest to implement the agreement as soon as possible. “We do believe that [implementation] will impact on NCHDs’ working lives and should impact positively on their willingness to stay and willingness to return to work in Ireland, but we are by no means finished. That is what the new contract is going to set out to achieve.…”

Currently, there is a weariness among the wider NCHD population, which does not augur well for recruitment
and retention.

“Everyone is jaded… there is a huge amount of trauma, I think, across the NCHD population,” commented Dr McNamara. “For a lot of them, they have not had a break since Covid. I hate to mention the ‘C’ word, but there is no real let-up. In times gone by, there was a kind of a let-up in terms of activity within healthcare sites over the summer months… the clinical work would be lighter. But right through the year now, there is a huge amount of overcrowding, high attendance rates, and outbreaks of infectious diseases.

“There is no let-up in it really unless people take a career break themselves; there is no natural break. So we do have to build in a sustainable working model for NCHDs so they can work in a way that means they don’t burnout, that they don’t have to be consistently working beyond their means.”

Meanwhile, as to NCHD perspectives on the new public-only consultant contract, Dr McNamara confirmed the views were “mixed” and varied “quite widely” across specialties.

At the IMO’s AGM in April, consultants strongly queried how measures on rostering and work locations will be implemented. While some specialties have broadly welcomed the contract, Dr McNamara said this did not negate the need to address the outstanding concerns of others.

“The concerns that certain specialties have about the public-only contract need to be addressed because there is a huge urgency to recruit into those specialties as well at consultant level.”