When a housing crisis meets a healthcare crisis

This country’s accommodation crisis is another prohibitive factor in healthcare recruitment, while many rotating NCHDs continue to face the unsustainable pressures of ‘double rent’. Catherine Reilly reports

Ireland’s housing crisis is increasingly impacting on health service recruitment and retention. This was evident from comments in November 2022 by the Director of Nursing and Midwifery at the National Maternity Hospital (NMH) in Dublin, Ms Mary Brosnan.

The NMH would usually have 35 voluntary turnovers of nursing and midwifery staff annually, but already it had 62, “so it’s pretty stark,” she told The Pat Kenny Show.

“When we meet the staff who are leaving and do exit interviews, primarily the reason they are giving is the cost of rent increasing – an inability to pay the increases or an unwillingness to pay the increases because there are cheaper options outside of Dublin.”

Ms Brosnan said it was “time to look at the whole Dublin weighting issue. If you work in a London hospital you will earn £6,500 extra as a London weighting. I think somehow that has to be addressed and looked at.”

On 8 November, the Irish Nurses and Midwives Organisation (INMO) wrote to Minister for Housing Darragh O’Brien about the “lack of affordable housing available for nurses and midwives in the greater Dublin area and in other rent pressure areas around this country”.

General Secretary Ms Phil Ní Sheaghdha referred to a large Dublin teaching hospital where only 43 per cent of the most recent graduating class remained, “with the lack of affordable housing being a major factor in nurses not choosing to work in that hospital.”

Nurses and midwives recruited from abroad were also advising the INMO that they were not prepared in advance for the lack of suitable affordable accommodation.

“Two Indian nurses recently recruited to a Dublin teaching hospital advise that they were placed in accommodation in Straffan, Co Kildare for the first 28 days of orientation, they were without public transport links and rosters commenced at 7.30 am.”

Ms Ní Sheaghdha called on the Government to invest in a capital plan to build and subsidise city centre accommodation for “essential workers”. She said this was a feature of recruitment and retention of nurses and midwives in most big cities in the UK, US, and Australia, “which are the main countries recruiting nurses/midwives from Ireland.”

In response to queries from the Medical Independent (MI), the Department of Housing provided no indication that it planned to introduce specific measures to support healthcare staff. A spokesperson referred to affordability schemes under the Housing for All strategy and a target of 300,000 homes over the next decade for social, affordable and cost rental, private rental, and private ownership housing.

“Affordability is something this Department takes very seriously, and affordable homes will help all people and professions, including key workers, such as healthcare staff,” said the spokesperson. “The Minister has received a meeting request from the INMO and that meeting will be scheduled shortly.”

HSE

The HSE has recently established a national programme “which aims at adopting a strategic health service response” to difficulties attracting and retaining healthcare workers.

A HSE spokesperson commented: “This strategic programme of work having identified challenges to workforce growth is developing a key set of actions…. The availability of affordable accommodation is one of the barriers identified and potential solutions are currently being explored to alleviate the challenges.”

Over the past three years the HSE had increased its overall staff numbers by over 17,000 and this trajectory “must continue in order to meet the healthcare needs of our growing and aging population”.

“Despite the significant growth over the last number of years, the HSE fully understands the resourcing challenges that we face as we are operating in a fiercely competitive global recruitment market.

“There are many factors, which create challenges to the overall growth of our workforce inclusive of the significant gap between supply and demand, competition from abroad, and the availability of affordable accommodation. Therefore, recruitment and workforce has been identified as a risk on the HSE risk register and mitigating actions put in place.”

NCHD-specific issues

A housing crisis within a housing crisis is the reality facing NCHDs required to rotate across regions for training – most recently this month.

The NCHD relocation payment increased from €500 to €1,000 under the recent agreement between the IMO and healthcare management. However, relocation costs above this amount and the ongoing costs of double renting or concurrent rent and mortgage payments are borne by NCHDs. As part of the IMO agreement, the Department of Health and HSE acknowledged “a particular issue for NCHDs who rotate and have to rent a second residence”. The parties agreed “measures are required to address this specific issue and such measures will be agreed between relevant parties as a matter of priority”.

MI understands the IMO has proposed a system of tax relief for NCHDs in these circumstances. The union supports greater regionalisation of training to minimise the need for doctors to uproot from their accommodation, but regionalisation has not yet been systematically implemented. Rotations are driven by specialty-specific requirements, but also the service provision needs of the health system. 

NCHD committee member Dr Brian Doyle told MI NCHDs may move across regions several times during specialty training, which lasts around a decade in many specialties.

“Anytime you move, or you leave your apartment or your house, you lose all the protections that go with that, you are losing the rent controls that go with it,” he said. “Then you are trying to uproot and like anyone else, in the middle of a housing crisis, find new accommodation, often in areas that are in very, very high demand, like the major cities, in particular, but also in rural areas. I don’t think there is anywhere in the country that you could easily find accommodation of any standard or any type at the moment.”

“For NCHDs, we are talking about frontline workers in our health system who are under huge strain and pressure as it is, in terms of their working hours. Many of our NCHDs are working 60-, 70-, 80-hour weeks, working every second if not every third weekend, and in addition to that, moving jobs and trying to find accommodation is a huge stress for people.”

The level of advance notice by training bodies to trainees of their rotation locations is variable, stated Dr Doyle.

The unfavourable circumstances facing rotating NCHDs means some are staying in hotel or B&B accommodation while looking for suitable alternatives, or commuting very long distances, which Dr Doyle noted as a concern for doctor and patient safety.

“It is happening at the moment that NCHDs will often just take the longer commute, which could be up to 90 minutes or two hours in each direction every day,” he outlined.

There has been a “huge push to talk about regionalising training”, which he considered would relieve stress and burnout and make medical training “more conducive to normal life”. However, he said that regionalisation has not been implemented at the required level.

“Some of the training bodies, even in the last 12 months, have increased the level of rotation for NCHDs in order, I assume, to help alleviate the burden of NCHD recruitment and retention issues in hospitals in regional areas,” he said. “I don’t accept that the training bodies are pursuing regionalisation at any great speed…. We do need to do it. I think regionalising training will make recruitment and retention better; it will open up the specialties that were traditionally seen as male dominated and not very family friendly, it would open up those specialties to more diversity….”

Dr Doyle underlined that the costs borne by rotating NCHDs must be addressed independent of whether there is a wider housing crisis.

“In any other industry your employer would pay for that in full,” he said of circumstances where employees are required to work in different locations. “If they are not going to do that, they have to recognise that NCHDs are paying for it themselves and need to look at something like tax relief.”

More broadly, the national accommodation crisis is a prohibitive factor in doctor recruitment and retention, according to Dr Doyle.

“The consultant staffing crisis is well documented and it is essential we sort that out longer term to try and alleviate the medical staffing crisis we have in hospitals at the moment…. At the stage of your career when you are a consultant, very many people will have family commitments, and if you are not able to find suitable accommodation for your partner, children, that is going to be a deciding factor in coming back to a health system which is overrun…. That whole picture makes the prospect of coming home to work in Ireland very, very unattractive.”

Forum

The Forum of Irish Postgraduate Medical Training Bodies has expressed “our collective and serious concerns” to the Department of Health’s NCHD taskforce regarding the accommodation crisis facing trainees.

Mr Martin McCormack, Honorary Secretary of the Forum, said the issue was three-fold – “a supply-demand problem compounded by rising rental costs
and further exacerbated by the extent to which trainees are required to
move accommodation”.

He continued: “Within and outside rent pressure zones there are limits to increases in rent (eg, 24 months from start of tenancy) and the requirement to move to accommodation elsewhere (necessary for training) deprives trainees of these protections in many instances.”

“A glaring difference between sitting tenants and those moving accommodation has arisen over the past five years.  Prof Ronan Lyons [Professor of Economics, Trinity College] has noted that the gap in rent increases since 2017 in Dublin is 28 per cent for movers and 15 per cent for stayers and is 50 per cent versus 6 per cent in the rest of the country.

“According to the CSO and the consumer price index, prices on average were 7.8 per cent greater in May 2022 compared with May 2021. The most notable changes in the year were increases in costs of housing, fuel, and transport at 16.5 per cent. Indeed, the latest Daft.ie report revealed that the average new rental costs have increased by 12 per cent over the past year with the average monthly rental reported to be more than €1,300; even more remarkable is the recent report that only 850 properties were available to rent across the State.”

Mr McCormack said that while inflation has run at 8 per cent over the past year, NCHD salaries have increased by 1-to-2 per cent, thus giving a net reduction in “spending power” of 6-to-7 per cent.

“The Housing Agency of Ireland recommends a maximum amount to pay towards rent or mortgage of 35 per cent of one’s monthly disposable income before declaring a housing crisis. The figures above indicate that trainee doctors in Ireland are required to pay a much greater proportion of their income on accommodation. This situation places many trainee doctors in a position of financial difficulty and great distress. The fact that many trainee doctors are required to pay emergency tax on moving to another hospital within the HSE compounds the hardship.”

He added: “Although this is a complex problem and, clearly, trainee doctors are not the only people who are suffering because of the housing crisis in Ireland, a national corrective intervention is urgently required. Previously and elsewhere, schemes have been put in place to counter housing inflicted financial hardship that might be considered now.  These include the ‘living out’ allowance in Ireland, salary sacrifice in Australia, and the key worker living schemes in the UK and Australia. Incorporating the moving allowance into the first month’s pay and offering HSE/hospital loan rentals are other options to consider.”

The latter option would involve provision of subsidised housing assistance, “whereby the State/clinical site would release some accommodation that they own, and is appropriate for living in, and would make it available on a subsidised basis to health professionals.”

The current situation was a “serious problem”, acknowledged Mr McCormack. It had “immediate implications for trainee retention and wellbeing”.

On greater regionalisation of training, Mr McCormack said it was a “very complex area”, but he did not agree with suggestions it had not advanced significantly.

He said HSE National Doctors Training and Planning, the Minister for Health and Department, and the Forum, had committed to accelerating improvements to postgraduate training in Ireland.  

In line with the planned establishment of six regional health areas (RHAs), each training body was “assessing readiness” to align allocations of doctors on their accredited training programmes with RHAs.

Mr McCormack, who is also CEO of the College of Anaesthesiologists, added: “Our training programme, for example, is different to other training programmes as it is run-through and runs over six years and due to the nature of the training and the sub-specialities (neuro anaesthesia, cardiothoracic, obstetrics, and paediatrics) it is not possible to train within the same RHA. However, we have developed a model to allow that no trainee should be allocated to more than two RHA regions, that every trainee has to spend more than 12 months outside Dublin and at least 12 months in a model 3 hospitals, but no longer than 24 months in any one hospital. The work is ongoing.”

The ICGP informed MI it had “not been contacted regarding accommodation issues for trainees or GPs from overseas coming to Ireland”. However, it was a matter “we continue to monitor”.

According to the RCPI, it “regularly consults” with trainees, members and fellows on various matters. “Ongoing consultation is underway across the country on a range of advocacy issues,” said a spokesperson.

The RCSI stated that the availability and/or affordability of accommodation was “not a major issue that trainees have been raising with us”.

“However, it is something the College is acutely aware of and we have introduced four-year pre-defined rotations across the majority of our specialty training programmes to assist trainees.”

In relation to reducing the geographical coverage of rotations, the RCSI, in partnership with the Saolta University Health Care Group, has developed a pilot four-year rotation model where surgical trainees will remain within the geographic area of the Group. “Trainees will commence within these new rotations in July 2023…. We have also increased the number of approved speciality training posts within the Saolta Group to facilitate this new model.”