The Department of Finance and the Minister for Health are in direct conflict on whether public patients should receive healthcare primarily from hospital consultants rather than junior doctors.
Concern in the Department of Finance about the potential cost of offering public patients the same quality care as private patients apparently underlies this latest dispute between the two Departments.
In correspondence released to The Irish Times under the Freedom of Information Act, the Department of Finance disputes that consultant-provided healthcare should necessarily be offered to public patients - as it is to private patients.
This is despite the commitment of the Minister for Health, Mr Martin, to this approach, intended to deliver higher quality equitable care to public patients. This would clearly require a substantial increase in the number of consultants.
The Government last year decided not to support the Minister for Health's policy until it received further information on its costs, which will not now be available until after the election.
In a letter, the Department of Finance insists a "consultant-provided" service should not be considered the "sole option" for the public health service.
However, the Minister for Health, Mr Martin, has said that the service had "to move from consultant-led to consultant-provided" in a live discussion of equity for public patients in RTÉ Radio's The Truth About the Health Service series on Monday.
In a further letter, the secretary general of the Department of Health, Mr Michael Kelly, wrote back to the Department of Finance pointing out that overdependence on junior doctors had "implications for safety of diagnosis and treatment".
This conflict also has an immediate bearing on the crisis in Accident and Emergency since the Medical Manpower Forum, which recommended a change to a consultant-provided service for all patients, found overdependence of the public hospital system on junior doctors.
It concluded this contributed "to patients having to remain in the A&E department for lengthy periods or being kept in acute beds longer than is necessary with the consequence that other patients in need are not able to secure beds".
The latest conflict has emerged from an exchange of letters between the Departments of Finance and Health this year. The adoption of a consultant-provided approach is not "indispensable", Finance asserted.
It requested the Department of Health to examine other models of care in the National Task Force on Medical Staffing, which met for the first time on February 21st and has been asked to report within nine months.
The establishment of the large and potentially unwieldy National Task Force on Medical Staffing was decided on by the Government last year when it noted, but failed to endorse, the Medical Manpower Forum's recommendation of a consultant-provided service.
At a meeting on April 3rd, 2001, the Government decided no commitment was to be given to the implementation of a consultant-provided service until it had been costed and negotiations concluded with the medical organisations.
Therefore, after the forum's three years of deliberations, yet another body has been established, which the Department of Finance wishes to repeat the work of the earlier bodies. The Department of Finance is represented on the steering group of the task force, which must cost a consultant-provided service.
In a letter on January 7th nominating the Finance representative to this steering group and addressed to Mr Michael Kelly, secretary general of the Department of Health, Mr David Doyle, second secretary of the Department of Finance, wrote: "While the studies done to date point in the direction of a consultant-provided, rather than a consultant-led, public hospital service, the Government have not endorsed this pending their further consideration of the matter in the light of the outcome of the substantive work now commencing."
He added: "Given the significance of what is involved, not least in terms of its potential financial implications, it is essential that the steering group does not approach its work on the basis that a consultant provided approach is the sole option - which, clearly, it is not."
Mr Kelly responded, with some acerbity, on January 24th: "We would view as very undesirable any question of effectively rewriting the Forum and Hanly reports (on junior doctors' hours). The core issues are well rehearsed.
"Every analysis to date comes back to the same key point: service provision in the Irish hospital system is overdependent on doctors who, while still in training, are required to provide 24-hour, seven-day medical care. While this care is formally under the supervision of individual consultants, their presence on site is in the main limited to 33 hours per week provided between 9 a.m.-5 p.m. Monday-Friday.
"Patients therefore have limited access to appropriate levels of senior clinical decision-making, with inherent implications for safety of diagnosis and treatment on the one hand and efficiency and cost-effectiveness on the other."
He continued: "The task force will no doubt examine alternative approaches but it must do so in the context of patient safety and quality of treatment."
The letters are reproduced in part in the accompanying panel.