Wednesday, 11 February 2009

The Spin Doctors Against Doctors.

Posted by: Dr Jane Doe.

"If you, would like to call me lazy, just go ahead now. And if you, would like to call me greedy, just go ahead now."

The HSE is targeting the most vulnerable group in the health service for extreme cutbacks currently, and disproportionately compared to the cuts being proposed elsewhere.
Among the cuts being proposed are:

• Mandatory 1 hour unpaid meal break
• Suspension of Training Grant and PGMDB Allowance
• Discontinuation of Higher Degree and Diploma Allowance
• Attendance at in-house training no longer paid
• Discontinuation of Living Out Allowance
• Introduction of mandatory unpaid Pre call/Post call
• Overtime payment: Monday to Saturday
• First 9 hours paid at flat time
• Balance of hours T + ¼
• Sunday & Public Holidays T x 2

In addition the HSE is aiming to introduce the following measures:
• Rosters formulated 8am to 8pm
• Hospitals to examine and eliminate unnecessary layers of on-call
• Maximisation of on call off site where feasible
• Cross cover across different specialities to be maximised
• Full roll out of successfully concluded NIG pilots
• Interns employed on 48 hour week from 1 July 2009

In addition to these cuts specifically aimed at NCHDs, as public servants you will also be subject to the Government’s proposed pension levy which will result in between a 6.4% and 8.5% deduction from your overall salary. (I might add that, although the pension levy that NCHDs pay is based on their income PLUS overtime-ie if you make 60K a year you will pay the proportionate levy-the pension NCHDs will accrue is based only on their BASIC pay. Food for thought, no?)

Before the recession hit Ireland NCHDs (Non Consultant Hospital Doctors-ie; interns, Senior House Officers, registrars and Specialist registrars, often called junior doctors despite the fact that many of them are in their forties!) enjoyed wonderful working conditions. Ah the Celtic Tiger. Truly a golden age.


The Famous Overtime Pay!

We worked anywhere from 60-120 hours per week. Our hourly rate was about ten euro less per hour than a primary school teacher. We did weekends “on call” which is a silly and grossly misunderstood euphemism for just plain old working, that lasted anywhere from 56 to 72 hours straight-with NO SLEEP BREAKS OR MEAL BREAKS SCHEDULED.
Our so called public service “job security” consisted of having to reapply for jobs and do interviews all around the country every six months to a year, indefinitely. We were shifted from hospital to hospital every three to six months, often in different parts of the country working with a whole new set of people and having to get used to a new hospital. We weren’t given so much as a day off to move house if we were rotated from say, Galway to Dublin, and many NCHDs moved themselves, their possessions and their families to new locations overnight and started a new job the next morning after pulling a change of clothes and their stethoscopes out of the boxes in the hall.

If we became sick while in the middle of a shift that could last anywhere from 32 to 72 hours then we had to keep working. If we were vomiting, had diarrhoea, had a high temperature, whatever. We had to keep working. If you became ill during the office hours of HR and management (9-5 Monday to Friday) then if you informed them they would often get angry with you, following which they would try and bully one of your colleagues to work the “on call” shift instead. Before even attempting to get a locum sometimes. The “on call” shift means that the person, who started work at 8 or 9 in the morning, has to stay on and keep working continuously all day, all night, and then resume their normal duties again the next day as though they hadn’t just been up all night working after working a full day too. 32 hour long shift-minimum. Usually it was more because one was so much slower at everything after already having done 24 hours straight with no sleep.

When we worked weekends, we worked all the next week too. In many hospitals around the country this meant that we came in on Saturday morning to work, and worked until Monday evening. No scheduled sleep break. No scheduled meal break. Even if you dared to have a shower you kept a nervous eye on your bleep. Often for most of this 72 hour shift we were continuously awake, and unfit to drive home on Monday evening. Following this marathon of insanity, we came back to work, bright and early, on Tuesday morning and continued working the week. Often there was another 32 shift ahead of us that week.

Yes, we were paid overtime at rates determined by the Labour Court. Time and a quarter for the first 15 hours after one went over 39 hours in the week, then time and a half thereafter. So after you had worked 39 hours, from hour 39 to hour 54 you were paid time and a quarter. From hour 54 onwards you were paid time and a half.
The Irish media has made quite the sensation of this. However, they forgot one teensy, weensy leetle detail.



The above working conditions have not changed and are still in practice all over the country.

There is currently, in Ireland, not one single NCHD who wouldn’t gladly take a pay cut in exchange for a reduction in working hours that would ensure adequate staffing and not compromise patient care. I for one would gladly never ever work another 32 hour shift with no sleep, if I could work a 40 hour week and be paid my basic wage. But, and this is the really big but, these OVERTIME HOURS ARE MANDATORY AND IT IS A BREACH OF CONTRACT TO REFUSE TO WORK THEM. We are contractually obligated to work an unspecified number (ie. however much they tell you to) of hours of overtime in addition to the normal 39 hour week. In addition, were we to all work only 48 hours a week, with the current staffing levels, patients would suffer and patient care would deteriorate drastically.

When the media runs these sensational headlines “Junior Doctor in Wherever Earns 100K in Overtime” they don’t seem to mention what the junior doctor was obligated to do to be paid that wage. This amount of overtime means that this doctor was working approx 120 hours a week, and was a registrar or an SpR. This means that he/she was doing 56-72 hour shifts with no sleep breaks at weekends and doing them every second or third weekend. This means that this doctor was chronically exhausted, never saw his/her family, drove a car and endangered their lives and the lives of others on the road while under the influence of severe fatigue. This means that the patients that he/she was treating were being treated by a medical professional who was so tired that their decision making abilities were akin to those of a person who was over the legal limit.

Personally, the unpaid days off pre and post call that the HSE are proposing sound almost humane to me. A 32-36 hour shift with no sleep or meal breaks will become a 16-24 hour shift instead. This is still insane, but more humane. And less dangerous. They will run into problems staffing the wards during the day, to be sure, if several people are off for two days because of a night on call. But overall, it will be preferable. For us.

The working conditions BEFORE the above proposals were already so bad that Irish trained doctors have been emigrating in the hundreds to Australia, New Zealand, the UK, USA and Canada. At earlier and earlier stages in their careers. Making the conditions worse is going to cause a torrential haemorrhage of doctors the like of which will not have been seen since the eighties.

The Mathematics of Overtime:

It often surprises me that people would become incensed by the thought of someone working 100 hours a week and getting paid for them. The fact remains that if ANYONE worked 100 hours a week doing whatever it is that they do and was paid for them, they would make a lot of money. Hell, if you were paid minimum wage, 8.65 per hour, and worked a 110 hour week like a surgical registrar on some crappy rota somewhere with no locum cover who never gets to see his/her family, you would make 951.50 that week. That’s 4281.75 per month. So if you make 20 euro an hour, then you come out with 9900 per month before tax. This is taxed at the high rate, so I don’t know, you probably get a lot less after, but still.

You see my point. If this junior doc with his 100k worked a 40 hour week instead of a 100 hour one, his salary would be nothing to write home about. If my buddy the primary teacher worked 110 hours a week, they would make 3630 per week gross as they’re on a higher hourly rate than an NCHD.

When NCHDs work a 40 hour week and get 100k, then that will be newsworthy. When they work 100 plus hours a week and get 100k that’s called basic mathematics. (If they worked 100 hours a week and got 40k this would also be newsworthy, as it would mean that registrar doctors in Ireland were paid approx 7 euro per hour, and this would be gross exploitation).

I’m not sure how the HSE thought that this spin was going to get the public on their side. Only an idiot would not be able to do the math here. (I used the calculator on my phone, but you take my point!) No matter how many stories they run about NCHDs working illegal unsafe hours being paid for those hours, they aren’t fooling anyone anymore. Maybe they should hire more doctors and divide our hours equally. Hmmm?

The Training Grant-and by extension, the training:

Being an NCHD in Ireland is an expensive business. One pays the Medical Council about 400-500 euro per year to stay on the register. The training grant does not cover this. Medical Indemnity insurance costs another couple of hundred euro, again out of your own pocket.

Things that the grant will cover:

To register your GPT-that is your General Professional Training, now changed to BST (Basic Specialist Training) which everyone has to register in order for their training to be accredited, it costs 2000 euro PER YEAR currently.

To register and pay for you training on the Surgical SHO scheme is currently 3200 per year. The scheme is two years long totalling 6400 euro just to do the scheme. This doesn’t pay for your exams.

The ACLS (Advanced Cardiac Life Support) course is mandatory for all medics working in an Irish hospital and must be redone every two years by every doctor. This course teaches basics like effective CPR, intubation and ventilation skills, defibrillation, and recognising abnormal cardiac rhythms and how to treat them. It costs 550 euro currently.

The equivalent for paediatric doctors is the PALS course (or APLS I believe it’s called elsewhere). Again, 550 euro, and an absolute requirement for work.

ATLS (Advanced Trauma Life Support) aimed at Accident and Emergency doctors-this one may even be more expensive than the ACLS or PALS as it takes longer.

Basic Surgical Skills courses can run from 500 upwards and teach trainee surgeons basics like suturing and operating skills.

The Royal College Membership exams (MRCPs) for General Medicine, Pathology, Psychiatry, Obstetrics and Paediatrics are requirements, respectively, for entry to specialist training schemes to train up the consultants of the future. The memberships have three parts, and each part costs 590 euro currently. So 1770euro to get these exams assuming you pass them all the first time. Which no-one does, believe me.

Prep courses for the membership exams cost 1000-2000 each sometimes. Particularly for the practical parts of the exams, they are vital.

The ACLS and PALS etc, are always on weekends, and hence one must often use one of the only weekends one is not on call in a month to do these courses.

Axing the training grant is, um, not such a hot idea. Doctors who don’t have the ACLS are probably not going to resuscitate you or your relatives properly. Or if the A&E doc didn’t do the ATLS, then all those RTAs wheeled in after hours are in serious trouble. Lack of doctors progressing through the ranks having obtained their membership exams means less staff at senior registrar and SpR level, and these are the most senior doctors in the hospital after hours, and the most knowledgeable.
Deskilling of the steadily decreasing pool of frontline medical staff is about as intelligent as raising taxes and decreasing incomes during a recession. Oh wait, it’s the same crowd as what done the recession in the first place.

Mandatory Unpaid One Hour Long Lunchbreaks:

HAHAHAHAHAHA! NCHDs getting LUNCH BREAKS? Okay. When did we EVER get LUNCH BREAKS? What planet are these people on? I know they probably think this would be awesome spin fodder, eg: “Fatcat overpaid junior doctors paid to just sit around eating”, but the public aren’t that stupid for heaven’s sake. There’s just no spin value to get out of this one, lads. Sorr-ree.

NCHDs carry their bleeps at all times and are available to work at all times when on duty. If you are called you have to go. None of us sit down to a nice lunch and coffee every day, or even ANY day. In addition, you can’t leave hospital grounds. Others can go to the bank or post office at lunch. Not us.

I remember many times eating a Snickers going down the hall and this served as my lunch and kept me until about 10pm when I might get a sandwich out of a vending machine and eat it with one hand while writing up an admission with the other.
I guess what they must want is for us to hand our bleeps en masse in to reception and head off downtown for lunch or for a nice hot meal in the hospital cafeteria. Cool! I’m down with that. As long as whoever has the bleep can handle the situations they are bleeped for. But wait! If all the NCHDs are on their (snigger) lunch break, then who will take care of the patients. Or are we not caring about that anymore because there’s a recession?

I suppose there could be staggered lunch breaks, but if they’re staggered then they sure can’t be a whole hour long. Otherwise you will have people going on their (chortle) lunch breaks at 4 and 5pm and such.

If the HSE would bother to engage with NCHDs and try to compromise then they might find that we are willing to help them devise rosters that decrease hours and consequently, overtime and still ensure enough staff are on at any given time to keep patients safe. They might find that we might be willing to limit the training grant to course fees and exam fees only, and forgo the one off laptop and equipment grant. They might even find that we might be willing to agree to a pay freeze. There are lots of ways we could help them to make savings, if we were to work together. In fact, if all health workers came together and we reorganised things a bit, we could still have a reasonable health service. Or maybe I’ve watched one too many Disney films.

But I suppose unilateral imposition of drastic alterations to our contracts without discussion and with lots of spin to try and further their cause is so much more effective. And industrial action and emigration on an EPIC scale of NCHDs trained at the taxpayers’ expense is a much better solution than us all working together to try and make the best of things.


  1. Phew! Do we get T x 2 for making it to the end of your beautifully articulated rant?

    This government has been hugely successful in creating a 'winter of discontent' for everyone, across the board. As you say, professional hard-working people were already leaving Ireland in droves (look at what happened to the nursing profession) because of working conditions. Recent government measures have only added fuel to the fire.

    I love Ireland but right now, I just want out of the place. Would the last person to leave, please switch off the lights!

  2. One thing that really bothers me about the cutbacks etc is that its the public sector that are taking it up the arse for the disaster of a situation we're in. The private sector created this mess so why aren't they taking the hit?

    re NHCD's v's the HSE I certainly hope the sort out this mess soon!

    ....wonder can I do my internship in oz/nz and skip the year of fun in ireland? i still have 4 years for them to sort it out back home, thank god.

  3. The thing is, Steph, that NCHDs are paying for this more so than any other worker in healthcare.

    We are subject to the levy. Fine. Then the pension thing. Fine.

    Now-the assault truly begins. And it would be one thing if we had it good already, but as I mentioned-the conditions were already so bad that the job was intolerable for a lot who saw sense and got out.

    Now it's unworkable. Everyone who can is going to leave,and the few who are left won't be able to afford to train up and will be inferiorly trained with a far greater workload.

    A recipe for disaster. I hope none of my family become ill in the next while. I am worried.

  4. Dr Doe, could you bring this brilliant piece that really sums everything up to the public press? It should not be given the poor treatment of being on a blog alone. We should all print this up and put it on our hospitals, even distribute it to the public (has to be a shortened version though)

  5. I understand and agree with all you say but wonder about your comparison to teachers. I am a junior doctor and my partner is a teacher in England. Are you calculating your hourly rate by assuming teachers get paid for four hour teaching time a day as is per usual in the media?

    My partner will easily work 12 hour days (though granted no nights and not always at weekends) so lets not start bashing the other professions to make ourselves feel more miserable.

  6. Luke-We'd bloody love to work 12 hour days. That seems short to me. Sorry.
    I have worked 56 hour days in the past.
    No really. I would start Saturday morning and end Monday evening. No day off on Tuesday either.
    Awake the whole time.
    I had a needlestick injury during one of these shifts because I was so tired I went half blind and stuck a syringe full of blood right through the first interdigital webspace of my left hand.
    I was then sent by a nurse to take blood from the patient for HIV antibodies, the patient had had a cardiac arrest and was dead. Needless to say it was difficult, and then we had to obtain consent from the relatives for the testing.
    For the rest of the 56 hour shift awake, I wondered if I'd contracted AIDS. I cried when I had time. I think that this sort of stress coupled with the inherent abuse of human rights that goes with forcing someone to work these shift lengths is worse than working a 12 hour day. The responsibility involved (running a cardiac arrest after having been awake for over 40 hours) is worse than working a 12 hour day.

    I based my figures on my friend's salaries-three are primary teachers and she informed me that she started on around 26 euro an hour. Nowadays in Ireland, teachers start on around 30 an hour I am told.

    I'm not bashing other professions to make anyone feel more miserable but I vomited from stress and exhaustion after this 56 hour shift. Not week. SHIFT. I worked a 70 hour week the week after. I still currently work 80-90 hours a week at times.

    Is your partner a primary school teacher? The kids are only there from about 9-3 so I'm assuming the rest of the work is either parent teacher meetings or lesson plans that can often be done from home (my mother is a primary teacher so I know what's involved) In addition to these hours we too do presentations, research papers, audits etc from home. We don't even consider the work from home to be work.

    I take it you are a doc in England and hence have the EWTD enforced to SOME degree. You are lucky. Very lucky. You should have some sympathy for those of us who are not so lucky.
    We might be headed your way real soon!

  7. Edit this .Publish it . Everywhere possible. Submit to be posted in all possible media. is good to post on and get to public without the HSE filter. The HSE pay 51 million to have the public believe the greedy lazy doctor spin. Broadsheet letters section. Email to Eamonn Keane Newstalk and Matt Cooper Today fm and the radio one drivetime lady. Give Joe a miss. Try George, although he may not listen. Try Plank for a laugh. But please go public with an edited consise version. Do what we are paying the IMO to do. Because they wont. Get some voice disguise technology and go on the radio.Please. Make the effort you put into writing that piece worth it by circulating it. You owe it to yourself. And we would owe you.

  8. well written jane, this will sound a bit monthy pythonesque but we have it good now, I am worried we are going back to where I started as an Intern in the early 90's

    Overtime then was a joke, labour Court at the time sadi it wouldnt be right to actually pay junior doctors overtime as they didnt really do overtime in the sense that everyone else did. They believed that the real working week for junior doctors was 70 hours and that what you got paid for 70 hours was really the basic salary package hence we got paid at 50% (not 150% for additional hours)

    To make matters worse the contracts said we shouldnt work more than a 65 hour week on average. The hospitals took this to mena they didnt have to pay for more than 65 hours

    I was on a 1/4 which meant for a lot of the weeks we did a 1/3 when people were on leave (mat leave was a disaster we prayed the girls wouldnt get pregnant). hospitals wouldnt get locums. Average hours ranged from the mid 80's to over 100 when people were on leave. Bad when 35 of them were not paid, and you were getting half pay for 26 hours. So demoralising

    At least IMO got that sorted in 1997 and 2000 for us without the Labour Court who seem to have no love for doctors

    No training grant, paid own medical indemnity ( id dont think you do now just the supplementary full indemnity fro NCHD now is around 6,000, supplemental depends on grade but goes from 100 up to around 700. Not many people out there paying 700 + 450 (medical council) for the privilege of going to work ( add the mandatory training fee to occupy a training post (1200-3200) and having a job is almost more expensive than not having one

    No need for industrial action here though
    just wait the contract out and dont sign one for July, Use the free market that MAry Harney wants (save some money between now and then) a gamble though if all hold their nerve they will have to settle, in the short term they will need locums so can get paid better for shorter hours and chalk 6 months down to experience. If they dont get enough junior doctors to take up the posts they will have to negotiate properly

  9. Very informatic blog i like thsi information To register and pay for you training on the Surgical SHO scheme is currently 3200 per year.Medical Locum Work