The research findings provide an insight into Ireland’s health system from the perspective of non-EU migrant doctors working in Ireland. Respondents described the inward migration of non-EU trained doctors, i.e., the arrival of highly skilled migrant doctors to Ireland. This is classified as a brain gain from source countries to the Irish health system. Respondents detailed the de-skilling process, whereby some of those non-EU doctors who have migrated to Ireland encounter limited training opportunities and stalled career progression in the Irish health system – a process classified as brain waste. Finally, respondents highlight the emigration intentions of non-EU doctors dissatisfied with their career progression – indicating a second wave of doctor emigration from Ireland and another case of brain drain.
Brain gain: inward migration of doctors
Respondents considered that the demand for non-EU migrant doctors in Ireland was driven by the need to fill vacant, service (i.e., non-training) posts within the Irish health system.
‘They are trained there and we are getting them here just to cover the gap that we have from the system, and that’s it. . . we are just bringing them to. . . give them the hard work’ (Doctor 18).
‘Non-EU doctors . . . keep the system up and running’ (Doctor 2).
Parallels can be drawn with the experiences of non-EU migrant nurses [
4], who also perceived that their recruitment was to fill gaps within the system. Although the migration of doctors to Ireland represents an injection of considerable medical skills and experience into the health workforce, respondents felt that they had been recruited to work in posts with working conditions unacceptable to Irish-trained doctors, as this respondent explains
‘they didn’t have a choice, they just need us and that’s why they have to appoint us, that’s my feeling after being here for ten years’ (Doctor 23).
Another common theme in the interviews was whether or not retention-focused measures would be a more cost effective way of managing the medical workforce than doctor migration. This arose specifically in relation to the recent active international recruitment campaigns [
5,
34]. Respondents felt that retaining doctors already working in the Irish health system (Irish, EU and non-EU doctors) could be a more cost-effective solution for the Irish health system.
‘The cost of people going over there, interviewing everybody, bring the doctors here, ticket, flights, all fixed expenses. . . if you could improve the conditions of the doctors you are having you wouldn’t have gotten into this problem at the first place’ (Doctor 24).
‘this year India and Pakistan and brought a few doctors from there, but what about those who are already here, why don’t you keep them here?’ (Doctor 19).
Brain waste
As outlined earlier, a feature of the Irish health system is its reliance on junior hospital doctors (see Figure
1). Vacancies tend to be at the junior hospital doctor level, particularly ‘service posts’ which are not linked to formal postgraduate training schemes. These posts, which account for one in five junior hospital doctor posts [
35], contain a disproportionate number of non-EU migrant doctors [
36] and offer limited opportunities for career progression.
Salt defines brain waste as the de-skilling that occurs when highly skilled workers migrate into forms of employment that do not require the levels of skills and experience they had applied in their former post [
37]. Experiences of brain waste and stalled career progression ( ( Humphries N et al. ‘I am kind of in stalemate’. The experiences of non-EU migrant doctors in Ireland. In Buchan J, Wismar M, Glinos I, Bremner, J eds.
Health professional mobility in a changing Europe: new dynamics, mobile individuals and policy responses. European Observatory Studies Series. WHO Forthcoming 2014). were reported by respondents who felt that their medical careers were not progressing in Ireland, that they were becoming de-skilled. This was particularly true for those working in service posts which exist outside formal postgraduate training and career progression structures and which offer little or no opportunity for up-skilling. Respondents described their experiences in these posts as ‘filling in the blanks’ (Doctor 5), ‘not moving forward’ (Doctor 27) and of being a ‘labourer’ (Doctor 16).
‘ I know that we are doing a service job, it is just 100% a service job’ (Doctor 26).
Respondents who occupied these roles felt that they were becoming de-skilled in Ireland.
‘ When I came here I thought that when I go back home I should be able to do something more . . . I should carry some skills back home. But unfortunately if you see the graph it has started decreasing down, and it is coming down’ (Doctor 3).
‘Yes I had a great expectations, I thought . . . they will train me. Rather than training me I have been losing my skills you know, so it was a really, really upsetting’ (Doctor 3).
The frustration and hopelessness felt by these by these non-EU migrant doctors with regard to their professional development and career progression was palpable, a feeling that; ‘we don't have any future . . . don't have any hope’ (Doctor 16). Several respondents mentioned that they would not recommend Ireland as a suitable location for non-EU migrant doctors, largely because of the risk of becoming de-skilled.
‘Not to come to Ireland. . . This is not just my advice; this is the advice from everybody here, even from people in this country. If you want to go and make a good career out of it, good training, you must go to a different country, not to Ireland; it is just a waste of time here’ (Doctor 21).
Junior hospital doctor posts, both training and service posts, also require frequent moves between hospitals every 6 or 12 months, a process known as ‘rotation’. Non-EU migrant doctors working in service posts felt trapped, both in terms of the rotation system and in terms of their career progression.
‘They could be working as Registrars for 10 years in Ireland and will never get a Consultant post and I think that is not fair . . . They have families, they have to move every 6 months or every year, it is just not right’ (Doctor 18).
Respondents felt that the Irish health system should be up front with its non-EU migrant doctors and potential migrant doctors about the opportunities (or lack of opportunities) available to them in Ireland. Although there are employment opportunities in Ireland, there are limited opportunities for training or career progression and, because of the rotation system, involve frequent moves. There was a feeling that there was a level of misinformation in the recruitment process, as this respondent explains.
‘since they are lacking the doctors, to attract the doctors they are . . . manipulating the things. They are not giving true picture, they are trying to hide the things, they are giving the good picture and then not showing them the dark side’ (Doctor 7).
For those non-EU migrant doctors who were actively recruited to Ireland in 2011, assurances that were reportedly given to them regarding the continuation of their postgraduate training in Ireland were unrealised. As a result, these recruits found their career progression in Ireland stalled [
38,
39]. The discrepancy between the ambitions of non-EU migrant doctors and the service needs of the Irish health system meant that dissatisfaction was inevitable for many. ( Humphries N et al. ‘I am kind of in stalemate’. The experiences of non-EU migrant doctors in Ireland. In Buchan J, Wismar M, Glinos I, Bremner, J eds.
Health professional mobility in a changing Europe: new dynamics, mobile individuals and policy responses. European Observatory Studies Series X WHO Forthcoming 2014)
Many respondents (26/37) were actively considering their future options in terms of having plans to migrate to another country.
Brain drain: migrant doctors intent to emigrate
Of those 26 migrant doctor respondents who expressed intent to emigrate, the most frequently cited reasons related to career progression and the availability of postgraduate training opportunities. Dissatisfaction with the posts available to non-EU migrant doctors and the limited opportunities they presented was a recurring theme of interviews.
‘They need to make more positions for training. Or people will leave this country; because why should I waste my time here when I know that I could get a good chance in Australia or UK’ (Doctor 21).
‘I don’t think I have any career prospects, that is why we are planning to move. . . I can work of course indefinitely, but just the conditions doesn’t suit me anymore’ (Doctor 33).
‘Either you go back home at your Registrar level or you stay in Ireland and whole of your life you are a Registrar which is bad, you are not climbing up your career ladder’. (Doctor 27).
Respondents felt that they needed to move from Ireland in order to obtain the training necessary to progress their careers, citing countries such as the UK and Australia as offering better training and career progression opportunities.
‘So I think I have gained what I have gained, either I have to sacrifice and go to UK for my training to become a consultant or stay here all my life which is not good’ (Doctor 27).
The intention or decision to leave Ireland was almost always taken for reasons relating to their profession and the conditions attached to their work as a doctor in Ireland (e.g., rotation, career progression, postgraduate training). Having spent several years in Ireland already, 22/37 respondents were frustrated to find limited opportunities for career progression available to non-EU migrant doctors.
‘Good people who want to work hard, who can work, who have good skills and want to use them. In the end Irish system put a big wall in front of them and they leave Ireland’ (Doctor 4).
Even those who had managed to access postgraduate training in Ireland were convinced that they would need to leave Ireland to progress their careers and achieve a consultant post. This relates to the lack of consultant posts in the Irish health system. Although the lack of consultant posts affects all junior hospital doctors, respondents also felt that they were less likely than an Irish trained doctor to achieve career progression within the Irish health system, as these respondents explain:
‘It is just the system, you know this system itself, understand that most of us NCHDs we don't have any future’ (Doctor 16).
‘after having the SPR [Specialist Registrar] in here there are good chance in the Canada to get the consultant posts’ (Doctor 7).
‘the next level for me is consultant. If I don’t get it obviously I will have to go abroad, the place where I will get the post’ (Doctor 30).