A new report aims to quantify the flow of trainees in and out of Ireland and suggests strategies to increase retention rates, writes David Lynch
There has been a flurry of reports from HSE National Doctors Training and Planning (NDTP) in recent months. The stark recruitment and retention challenges in the model 3 hospitals sector were laid bare in a document published late last year, while a medical workforce strategy released in January stated the number of anaesthesiologists needed to nearly double by 2038 to meet rising demand.
The most recently released publication is the Annual Medical Retention Report 2023, which is the first of its kind. The NDTP said the “recent expansion” of its medical workforce planning team will now allow for this report to be published annually to document “the evolution” of doctor retention rates over time.
The aim of the report is to describe the flow of doctors leaving and returning to Ireland as they progress through the various stages of training. It also aims to present strategies to improve retention rates.
Comings and goings
- From the 2017 to 2020 cohorts of doctors who completed basic specialist training in Ireland, on average 77 per cent of these doctors went on to further training by 2023. Of this cohort, 85 per cent of Irish doctors went on to further training in Ireland, in comparison to 47 per cent of EU/UK doctors and only 43 per cent of non-EU doctors going on to further training in this country.
- 32 per cent of doctors that completed the IMGTI programme between 2015 and 2020 returned to their home country before going on to work in the Irish public health system for a period of time.
- Most fully qualified specialists leave the Irish health system after completing higher specialist training and being awarded a CSCST. According to the report, “they then return over subsequent years.”
- Of the 2016 and 2017 cohorts of CSCSTs, on average 68 per cent were working in the Irish health system (public and private) in 2023.
Changes
The report is published against the background of some changes at the NDTP. The HSE confirmed to this newspaper that Prof Brian Kinirons’s three-year term as NDTP Medical Director will be completed at the end of May and the search for a successor is underway.
The Executive is also seeking a person to take on the role of implementation lead in relation to model 3 hospitals. The spokesperson said the “primary purpose” of this new post is implementing the NDTP’s Model 3 Hospitals Report. In November, Prof Kinirons outlined to the Medical Independent (MI) the “significant and serious” challenges to service delivery due to consultant recruitment difficulties in the model 3 sector.
Conditions
The executive summary of the new retention report stated many interns leave the Irish health system after internship (see panel).
For the 2015 to 2022 intern cohorts, on average, 50 per cent left Ireland in the year after their internship. However, the “vast majority subsequently return” to take up a training post.
Career progression is a major driver of migration of qualified specialists. Most specialties “encourage trainees to migrate to achieve career progression”. The NDTP said the number of Fellowships available in Ireland post-certificate of satisfactory completion of specialist training (CSCST) “is relatively small”. For example, in 2022, there were 68 filled post-CSCST Fellowships compared to the 452 CSCST graduates in the same year.
Working conditions were highlighted as a “key disincentive” to returning to work in Ireland. The intention to go abroad is also associated with a negative experience of mentoring. This suggests that the quality of training, and how the training is provided, are important determinants of the intention of doctors to remain in Ireland.
In his foreword, Prof Kinirons writes that “the strong culture of migration among Irish people in their 20s is evident among doctors who complete their intern training”.
“While half of interns leave the Irish health system after completing internship, the overwhelming majority go on to further medical training in Ireland a number of years later.”
The report outlined a range of possible measures to improve retention. Some of these, according to Prof Kinirons, “may yield results in the short-term.”
While half of interns leave the Irish health system after completing internship, the overwhelming majority go on to further medical training in Ireland a number of years later
He cites proleptic appointments as an example of such a measure. Proleptic appointments are where a candidate is offered the post subject to them acquiring a particular qualification or skill within a certain period of time after appointment.
“Others, such as increasing the number of CAO medical places, will take many years to bear fruit.”
Generalism
The need for more generalists in the health service is referenced in the report. It noted that “generalism is seen as a strength of the Irish medical care and medical education system”.
In its recommendations, the report stated that policies “aimed at supporting generalist training and practice may be best suited to matching supply with population health needs in Ireland. Better matching of supply and demand for skills is likely to lead to improved retention.”
Asked what measures the HSE is taking to support generalist training into the future, the spokesperson noted that the NDTP is developing a suite of specialty specific medical workforce plans.
They said in parallel with these workforce plans, an “aggregate supply model” is at an advanced stage of development.
“The aim of this model is to bring together each of the 40-plus medical specialties into one model to generate a projection of the aggregate medical workforce expansion that can be achieved through increased training in each specialty.”
Speaking to MI at the National Health Summit in Dublin last month, the former Deputy Chief Medical Officer at the Department of Health, Dr Ronan Glynn, who is now Partner and Health Sector Lead at EY Ireland, said the medical education and training system would need to be altered “to train more generalists”, especially to work in rural areas.
Proleptic
The issue of proleptic appointments within the health service, which Prof Kinirons referred to, is flagged within the main report.
“No formal national proleptic appointments process currently exists,” the report concludes, “therefore, providing this may give our specialists an additional incentive to return within a shorter timeframe.”
The HSE’s spokesperson told MI there is “no formal plan” for proleptic appointments currently. The spokesperson did not indicate there was any plan to create such a process.
The NDTP’s model 3 report also recommended that a formal policy or process on proleptic appointments should be considered for the sector.
Fellowships
The report noted that historically in Ireland there were few post-CSCST Fellowships. However, in 2021, there was a “substantial increase” to 44 Fellowships.
In its recommendations, the NDTP indicated that there may be “substantial room” to further increase this figure.
“These post-CSCST Fellowships need to be aligned with future consultant opportunities.”
Asked if the Executive has any plans to increase the number of Fellowships, the spokesperson said that these posts are created through either the conversion of non-training posts, in which case the post may revert to either a specialist registrar post, a non-training post, or a post within the IMGTI [international medical graduate training initiative] programme, or through supernumerary/fully-funded post-CSCST Aspire Fellowships.
They added that the number of Aspire Fellowships was expanded in 2021 following a commitment by the Minister for Health to fund 40 such Fellowships on an annual basis, while “the number of post-CSCST Fellowships has substantially increased”. The number of filled post-CSCST Fellowships in 2022 was 68.
The HSE’s spokesperson said the number of post-CSCST Fellowships “will be kept under review”; however, any further increase would be subject to “funding requirements”.
The report is available at www.hse.ie/eng/staff/leadership-education-development/met/plan/annual-retention-report-2023.pdf
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