The Irish health system is ‘wasting a lot of talent’

In 2014, Dr Shirin Akhtar started working as a senior house officer (SHO) in the neonatal unit of Dublin’s National Maternity Hospital. The Bangladeshi doctor had taken a break from work after moving to Ireland with her husband in 2008 to care for her young children but was keen to embark on a new medical career in the Irish health service.

However, after completing her eligibility exams to work here, she discovered the career path she hoped for was impossible.

Having trained in Bangladesh, her internship was not recognised by the Irish Medical Council which meant she could not apply for specialist training and go on to become a consultant.

Dr Akhtar is now a paediatric registrar in Tallaght Hospital’s emergency department. “Back home in Bangladesh my friends have become consultants. Ireland needs more doctors and is recruiting us but then we’re not eligible for training. Knowing that makes you feel depressed.”

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Even if a candidate has previously worked as a general practitioner in their home country, they are not eligible

There are currently 6,318 doctors who trained abroad practising medicine in Ireland out of a total 17,925 “clinically active” doctors, according to data released to The Irish Times by the Irish Medical Council. Of these, 1,380 are Pakistani, 714 are Sudanese, 650 are from the UK, 517 are Romanian, 336 are South African, 277 are Egyptian and 197 are Polish.

At present, only foreign doctors with internships recognised by the Irish Medical Council can apply for trainee specialist schemes to become consultants or general practitioners. Even if a candidate has previously worked as a general practitioner in their home country, they are not eligible to re-train in the same speciality unless their internship is recognised by the Irish system.

Legislation seeking to amend the Medical Practitioners Act, which would remove the need to have an equivalent certificate of experience to qualify for specialist training, is currently going through the Oireachtas. The Regulated Professions (Health and Social Care) amendment Bill 2019 has completed all Dáil and Seanad stages but was referred back to the Dáil in September for further debate.

This Dáil discussion is "expected to take place in the near future," according to the Department of Health.

If the amendment passes, doctors seeking to apply for specialist training will still need to satisfy other requirements including “knowledge of English or Irish, being a fit and proper person, holding an approved training post, and meeting any other rules which registration on this division subjects registrants to,” said a department spokeswoman.

She added that junior doctors, regardless of where they were trained, had “identical entitlements to annual leave, study/educational leave,” while the Health Service Executive (HSE) offers support schemes to strengthen their “professional education, qualifications and career progress”.

Marta Karavisch de Moraes Rego, who graduated with a speciality in sports medicine in Brazil in 2011, is one of the many doctors eager to see the amendment pass as soon as possible. Dr Rego moved to Ireland last year to be with her Irish fiance and secured a job as an SHO in Blanchardstown's Connolly Hospital after passing her eligibility exams.

If the amendment passes, she will be able to apply to specialise. However, she knows other foreign doctors have been waiting years to see this change and is losing faith that she will be allowed to specialise in the near future.

“I don’t want to be an emergency doctor for the rest of my life, I’m looking to progress my career here,” says Dr Rego who now works in Cork University Hospital. “Even if they do pass the legislation they only take non-EU candidates after all the European candidates have been offered a place. People who were trained in other countries can bring good ideas but if you’re just an SHO you’re not in a position to speak up and give suggestions.

“A lot of us foreign doctors have huge experience from outside but we can’t use that experience here if we’re not progressing. The Irish system is wasting a lot of talent.”

Specialist medical training programmes are currently allocated with first preference going to Irish citizens followed by EU nationals. If any places are left, they’re offered to eligible candidates from outside the EU.

While the Irish Medical Council does recognise internships from a small handful of non-EEA countries – including Australia, New Zealand, Pakistan, South Africa and Sudan – securing a place on specialist training programme remains extremely difficult for those who studied outside Europe, says Dr Ehtasham Yousaf, a paediatric registrar who has been working in Ireland since 2015 and is now based at St Luke's Hospital in Kilkenny.

Dr Yousaf, who is from Pakistan, says he has been “continuously discouraged” from applying for specialist training and claims alternate career progression pathways which previously existed for those unable to secure a place on these courses have been blocked off.

Dr Yousaf admits he’s started losing faith in the Irish training system. “My target is to be a consultant, I don’t want to be a registrar for another 10 years. But nobody facilitates or guides us in our training. You can’t get on to the BST (Basic Specialist Training) or HST (High Specialist Training) because of the preference system.”

Dr Yousaf is considering moving to the UK for work. “I don’t want to leave Ireland, the people here are lovely and I’m happy. But when you’re discriminated against on the basis of your nationality you feel bad. We are serving the Irish people and want to be a part of this country. But because of the lack of opportunities I have to move on.”

Dr Ahmed Elsamani, a registrar at Our Lady’s Hospital in Navan, agrees that even when your internship is recognised, there is a lack of clarity around how foreign doctors should progress professionally. The Sudanese doctor who has worked in Ireland for five years says a single, unified approach to specialist training for non-EEA doctors is badly needed.

I don't mind waiting to become a consultant, as long as there's a pathway with an end in sight

Dr Elsamani ran his own practice in Sudan and worked for six years in Saudi Arabia before moving here. The death of Dr Syed Waqqar Ali, the locum doctor who died in July after contracting Covid-19, prompted Dr Elsamani to speak out about the barriers facing foreign doctors in Ireland. "This man was here for 20 years and was known for his hard work and excellence but he was never able to progress in his career and that saddened me. If there was a clear pathway he could have reached a point with a more settled life."

Dr Elsamani is also thinking about moving to the UK. “If things were clearer I’d probably stay. I don’t mind waiting to become a consultant, as long as there’s a pathway with an end in sight.”

He recently joined the Train us for Ireland campaign which was established in June as “a peaceful movement advocating for positive career changes” for foreign doctors. In a survey of 400 doctors carried out this summer, the group found nearly 88 per cent were considering leaving the HSE because of the professional barriers they face.

More than 97 respondents said they came to Ireland “with the expectation of career progression” while another 97 per cent agreed there were not “sufficient opportunities” for career development.

In a letter sent to training bodies and political representatives in July 2020, the group said foreign doctors were being prevented from building a career “despite the enticement from the HSE in their recruitment efforts”. The current legal barriers mean frustrated doctors must go “on the hunt for better career opportunities elsewhere despite already making Ireland their new home,” they wrote. Their negatives experiences are now discouraging other non-EEA doctors from applying to work for the HSE which has a “high dependency on non-scheme medical trainees to keep its healthcare system running”.

The letter calls on the State to “end discrimination against non-Irish/non-EU medical doctors when they apply for training posts” and to encourage training bodies “to clearly state the requirements for recognition of parallel training pathways”.

Dr Liqa ur Rehman, a neonatology registrar at Galway University Hospital who helped set up the campaign, says many of his colleagues were “reluctant to come forward because they’re scared of the repercussions”.

Dr ur Rehman worries the proposed legislative amendment around access to training will take a long time to pass and would like to see the HSE, medical council and other training bodies create a “well-structured alternative pathway to specialist training for foreign nationals” in the meantime.

“Even if the amendment goes through we’ll still be at the bottom of the list when we apply for training,” says Dr ur Rehman who moved here from New Zealand two years ago. “We need a recognised alternate pathway that is clear and transparent.”

Dr Moshin Kamal, who also helped establish the campaign and works as a registrar in infectious diseases at Children’s Health Ireland at Crumlin, says previous calls for change from non-EEA doctors have been ignored.

In a tweet posted in June 2020, Dr Kamal praised the HSE for increasing the number of training slots for Irish doctors returning from Australia and the USA but highlighted the lack of support for non-EU doctors already working in the country.

“We are working in the same system doing the same jobs as other doctors but still we have almost no training opportunities,” he tweeted. The loser in this would be the Irish health system, he said.

“I don’t see any career progression in Ireland, I have no future here,” the father-of-two told The Irish Times. “They don’t value our knowledge and experience. It’s the Irish system that’s losing out.”

In a report published in July, the HSE admitted a "considerable increase" in the number of "medical consultants/specialists and trainees" was urgently needed and warned of difficulties in recruiting consultants. The Irish Hospital Consultants Association (ICHA) said one in five permanent consultant posts were currently unfilled in public hospitals resulting in "unacceptable delays in providing care to patients and record waiting lists which are getting longer as a result of the pandemic".

Dr Lydia Sham, an Indian doctor who trained in Romania and moved to Ireland last year from Dubai, says the only non-EEA doctors she's seen progress are those who have secured an Irish passport and have worked in Ireland over a decade.

She agrees that many of her non-European colleagues fear they’ll lose their job if they speak up. “At least if you get a trainee position you have some stability in your life. It’s not easy being on a series of six-month contracts where you keep changing hospitals. I work, I earn money but what other progress am I gaining other than a few online courses to keep my registration in tact?”

Asked to comment on the legal barriers facing non-EEA doctors, a Medical Council of Ireland spokesman said the passing of the Regulated Professions (Health and Social Care) amendment Bill 2019 would resolve the problem and enable foreign doctors to register on the Trainee Specialist Division. This will open “access to doctors who are appropriately qualified and suitable for training, but without initial Irish basic medical training,” he said.

The Irish system is losing experienced doctors because of this

It is hoped these changes will allow doctors in long-term service roles to access further postgraduate education, professional development and progression within the Irish health system, rather than having to leave the country to further their career, he added.

Unless change happens soon, Ireland risks losing large numbers of highly capable, well-trained doctors, concludes Dr Akhtar. “Ireland is looking for consultants but they’re recruiting non-EU doctors who are not eligible for these positions. I know about 30 doctors who have left.”

Dr Akhtar, however, is not in a position to leave. “My husband works here, my kids are here, it’s not easy for us to move. I am an Irish citizen now, I’ve been working here for six years. I’d love to be in general paediatrics but I’m not eligible. The Irish system is losing experienced doctors because of this.”