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The brain drain

11 May 2015

 Medical migration from Ireland continues to gather pace.

Anecdotes abound of newly-qualified doctors leaving because of what they perceive as difficult working conditions at home and better training opportunities abroad. Some established general practitioners have decided to emigrate for economic reasons, citing the declining economic viability of practice in the Republic following a series of cuts to medical card fees imposed by government.

The Medical Council’s second annual Medical Workforce Intelligence Report, published in August, puts exact figures on what is happening. In a continuation of a trend identified in its first report, almost one in ten doctors aged 25-29 years exited the practice of medicine in Ireland during the previous year. This represents an annual relative increase of 23% in the exit rate among graduates of Irish medical schools in that age cohort. 

Some 5% of 25-29-year-old doctors on the medical register were practising outside Ireland. A relatively low exit rate was observed among doctors enrolled in the specialist division of the register, suggesting the departure of mature practitioners has yet to appear on the statistical radar. 

Casebook interviewed two general practitioners now settled in Canada and Australia to get a sense of why they left Ireland, what the major differences between the health systems are and in particular to get a feel for the medicolegal landscape in other jurisdictions. 

Dr Sunny Chan is a 1997 graduate of Queen’s University, Belfast. He completed GP training in 2003 and then moved to Dublin to work as a GP and lecturer in general practice at the Royal College of Surgeons in Ireland. After completing his doctorate in 2006, he found a shortage of tenured academic posts in Ireland. And negotiating partnerships in practices proved “a very arduous task”, he says. So in 2012 he decided to emigrate and arrived in Ottawa in January 2003 where he started his own practice in Kanata, just outside the centre of Canada’s capital city.

Dr Deborah Molloy graduated from Trinity College Dublin in 2006 and completed the TCD training scheme in 2013. After some eight months working as a locum in practices around Dublin, during which she considered buying a practice, she moved to Perth, Australia, primarily for financial reasons. She has been a GP there for the last six months. She works in a corporate practice with ten other family doctors in a socially deprived area of the city. It is a bulk-billing practice so patients do not have to pay the practice directly.

Apollo Health, who plan to expand from operating three to six GP centres in Perth, employ a number of different payment structures for doctors. Most have a contract whereby they give 35% of their income to the company as a management fee. “A colleague of mine has described this as being like a ‘sharecropper system’ whereby small farmers farm the land and give a portion of their earnings to the landowners,” Dr Molloy says. “At the moment I am seeing between 25-30 patients per day. Consult times vary from 10 to 20 minutes. There is no on-call commitment.”

For Dr Chan, Canada offered a number of potential models to practise as a family physician. Essentially GPs are independent contractors who bill their provincial Health Insurance Plan for work and services carried out on behalf of patients covered by that province. Patients who don’t have a GP or who require emergency care can attend separate ‘walk-in’ clinics. 

“Having always worked in a more traditional primary care model based on health prevention and continuity of care, I didn’t feel comfortable with providing ‘fast food’ style care to patients in a walk-in clinic,” Dr Chan says. “I chose to set up my own family practice in a health centre, joining three other GPs who have a similar philosophy in primary care. Within the model I work in there is very minimal 'on call’…I generally see between 20-25 patients per day.”

What are the biggest differences between the Canadian, Australian and Irish health systems? Dr Molloy points to similarities with the NHS, albeit without the waiting times. Prescribing is tightly regulated; she must contact a state authority before starting anything other than basic treatment. And GPs are expected to take on more responsibility for the management of early pregnancy complications.

Dr Chan says Canada has a universal health system offering free healthcare to all, but with differences between provinces. Many Canadians take out health insurance to cover the cost of medication. However there are long wait times for secondary care appointments and surgical procedures, and these cannot be improved by using private health cover. 

Dr Chan says he has noticed that patients in Canada will more readily complain to the provincial governing body if they are unhappy with a doctor, medical centre or even the doctor’s staff. “In Ireland during recent years I had noticed a sharp rise in medicolegal cases, possibly related to recessionary times.” 

The medicolegal systems in Australia and Canada are similar to Ireland. Doctors are obliged to have medical indemnity, which is provided by a single body in Canada whereas there is a choice of agencies in Australia. In both countries initial medicolegal advice is available by telephone. If a patient suffers an adverse outcome in general practice in Australia and wants to seek redress, Dr Molloy outlines the process: “If patients have a grievance the first option open to them is to fill in a form and give it to the administration staff in our clinic. The GP involved has the option of writing their own response.

“If the complaint is of a more serious nature the patient can write to AHPRA, which is equivalent to the Medical Council. Or alternatively the patient can seek legal advice from a solicitor.” Dr Chan describes the Canadian process as more propatient than in Ireland. “There is a culture for patients to call the college or council if they are unhappy about something. More patients are also more willing to report any grievance to the press no matter how small and trivial it may be.”

And when a patient suffers an adverse outcome and seeks redress Dr Chan says they “invariably go straight to their lawyer”, who will in turn serve notice on the doctor or health facility. Dr Molloy makes an interesting observation when she says that GPs in Ireland tended to get quite distressed about complaints and would be very quick to seek legal advice. “From what I can see the Australians seem to accept that people complain all the time and they seem to take this in their stride.” 

Looking back both would like to see some changes to the system in Ireland. Quicker resolution of claims and a more protective Medical Council environment are top of their respective wish-lists.

Medical Workforce Intelligence Report 2014 – main findings

Source: Medical Council August 2014

1 in 5 doctors in Ireland are aged 55 or older
1 in 3 doctors practising in Ireland qualified elsewhere
4 in 10 doctors on the register are women
Women are twice as likely as men to work part-time
Almost 1 in 10 doctors aged 25-29 left the practice of medicine in Ireland during the past year