As nurses escalate their industrial action and consultant doctors dispute the HSE's proposed contracts, Kathy Sheridanexamines their cases
Spin and counter spin. The HSE talked of "near-misses" for patients in the nurses' work stoppages and said we were only hours from a serious incident. The nurses insisted there were no such thing and anyway, if there were, it was all the fault of the Minister for Health, Mary Harney.
The HSE continued to trot out the "average" nurse's earnings at €56,000 a year. The nurses' placards claimed it was €28,878.
So who came out worst this week? That would probably be Dr Josh Keaveny, the consultant who reportedly told a press conference that a proposed €205,000 salary for the new consultants' posts was "Mickey Mouse". "Mary Harney must have thought Christmas had come early," sighed a Beaumont hospital colleague, as the pundits revved up for another run at the inflexible, arrogant, golfing sultans of medicine.
The problem is (as he writes on today's Letters page) that this is not quite what Dr Keaveny said. As a delegate on the negotiating team of the Irish Hospital Consultants' Association (IHCA), he was speaking about the 68 new consultant posts advertised on Thursday, after talks had collapsed between consultants and the HSE about a new contract. What he actually said was that anyone who had spent 14 years training to be a consultant and was now on half a million dollars a year in the US, was unlikely to return to Ireland for a job with no agreed contract or salary. "I was talking about the HSE process as being Mickey Mouse. I'm really gutted by the way this was picked up," he says.
However it was interpreted, the damage was done. Both the Taoiseach and the Minister for Health were happy to reach for the "Mickey Mouse" reference, in suitably doleful tones. The IHCA had been at pains to stress that their gripe with the new contracts was not about money; the implication now was that it was.
IN THIS GAME, image is crucial. The side with public support is the one with the leverage. Just 43 per cent of those who took part in the online survey conducted by the Irish Medical News this week said they supported the action by the Irish Nurses' Organisation (INO) and the Psychiatric Nurses' Organisation (PNA). And 56 per cent of people who responded to a poll on ireland.com said industrial action by nurses is damaging their reputation in Ireland.
But for the public, sifting fact from a sack of spin, counter-spin and public service jargon is virtually impossible. Public discourse about the nurses' dispute has revealed deep ambivalence about the nature of nurses' work, what they are worth financially, and their status in relation to other public servants.
The "anomaly" by which some 50 staff nurses were found to be earning less than the social-care workers who reported to them, is rooted in a serious shortage of people prepared to work with challenging teenagers in residential-care homes. This became a central plank, however, in the 10.6 per cent pay claim for all nurses. "How would Mary Harney feel if her tea lady was earning more money than her?" asked a nurse on a picket line, a question that forced social-care workers to come out and defend their work.
Nurses have also raised hackles by going on the airwaves and making special cases of themselves, seeking compensation for long commuting times, living in Dublin, car-parking costs, and childcare. In return, the phone lines were scorched by private sector workers in insecure jobs, who endure precisely the same conditions, while also working harder than ever, for longer hours, under increasing pressure, but who could only watch with envy as the nurses availed of the benchmarking ATM available only to public servants.
Part of the nurses' complaint is that, as a degree profession, they did badly out of Benchmarking 1, being compared, they believe, with prison officers and gardaí. But they were not a degree profession back then, remarks one sometime negotiator. "Now that they are, they should have a decent argument under benchmarking. If they have so much conviction that right is on their side, why are they afraid to go to benchmarking ? If it's good enough for 300,000 public servants, it should be good enough for the INO and the PNA."
A senior nursing figure agrees. "If the INO claims that benchmarking let nursing down so badly, knowing that it's the Taoiseach's treasured legacy and the basis (some would argue) for economic peace and prosperity, why did they not make an extremely strong submission to the next round of benchmarking, which is so close, wait and see if nursing did better this time, and if not, then reject it? I simply can't understand this. No one can . . . Why go the strike route? It is rather ironic. We want to be treated and paid like a profession, but we are acting like members of a trade union. What the INO is saying is 'we will act like a non-profession until you pay us as one' . . ."
The same nursing officer points to another problem for nurses, in terms of image, cohesion and skill mix, which is their sheer number. There are some 40,000 of them, with wildly varying powers and responsibilities. "Maybe 10,000 of those could be carrying out domestic/household/clerical duties, whereas another 10,000 could be working to a very high level of responsibility: carrying a patient workload; making autonomous decisions; diagnosing; requesting X-rays and bloods; interpreting them; prescribing treatment options; referring to other members of the healthcare team and so on."
This latter cohort of clinical nurse/midwife specialists - or Advanced Nurse Practitioners - comprises just 1,850 but points the way for ambitious, entrepreneurial nurses.
Those numbers also have implications for any awards, however minimal. For example, the HSE estimates that ceding a 35-hour week would immediately take 7.7 million hours out of the system and does not accept the repeated claim that nurses are calling in a 27-year-old promise. What the Labour Court actually said in 1980 was that "if there is to be a general reduction in hours of work for people who now work a 40-hour week, psychiatric nurses should be amongst the first to benefit". Nurses were among the beneficiaries when a 39-hour week was introduced in 1991. In 2003, the Labour Court referred their claim to the Public Service Benchmarking Body.
"So there was no promise, ever," says Brendan Mulligan of the HSE, who points out that 70 per cent of health service workers work a 39-hour week. "The latest recommendation of the court has provided a framework under which a reduced working week may be possible. Any change will have to be on a cost-neutral basis." And who, then, are the 30 per cent of the health service already on the rather desirable 35-hour week? That, oddly, would include the management and clerical/administration grades.
WHILE MOST OF those involved agree that there is room for manoeuvre about hours reduction, the door seems firmly shut on the 10.6 per cent pay increase. Salaries have become the most contentious part of this dispute. Mulligan says baldly that nurses have been "telling lies" to the public about their true earnings and he "absolutely stands by" the figure of €56,000 the HSE has given for average earnings.
The HSE points out that for every staff nurse post, there are 2.7 promotional posts. But a quarter of all nurses work fewer than 39 hours, opting for part-time or job-sharing. The €56,000 amount is reached by averaging the earnings of all nurses.
The earnings of frontline staff nurses, who comprise 38 per cent of the total, have been a particular bone of contention.
Figures compiled by the HSE for total earnings include allowances such as "premium earnings" - a fifth of the basic salary - for night duty and Sunday work within the 39-hour week, plus a qualification or "locational" allowance of €2,741 or €1,825 (for which 70 per cent are eligible).
Thus a typical staff nurse after 11 years (some 30 per cent of nurses), on the maximum basic of €43,430, plus the 20 per cent premium of €8,686, plus the qualification allowance of €2,741, makes a total of €54,857. The 24 per cent of nurses who have served 10 years, on this calculation, have total earnings of €53,245, while after six years, the total would be €47,118.
These figures compare to a physiotherapist's maximum salary of €49,717 or a "professionally-qualified" social worker's €56,634.
Had they been part of the social partnership agreement, nurses would also have received another 3 per cent last December and a further 2 per cent in June.
But, you might think, the earnings of the most powerful women in the profession, the directors of nursing (once known as matrons), surely bring up the average? Not by a lot. They earn a maximum of just €85,419. It's a long way from the typical earnings of say, a hospital consultant - and they are also deep in discussions with the HSE.
The widespread perception, not discouraged by the HSE, is that inflexible, fat-cat consultants and not a lack of beds or facilities are at the root of a dysfunctional health service. The HSE answer, it seems, lies in 2,000 extra consultants in tandem with the HSE taking absolute control of consultants' hours and practice plans.
The consultants respond that the HSE wants "100 per cent authority with consultants taking 100 per cent responsibility". This is a war for control, they say. They eye the HSE's growing corporate empire (36 CEOs, 16 deputy CEOs, 90 general managers, 51 hospital administrators), the mushrooming private hospital sector being facilitated by the Government, and insist that, no matter how many consultants are appointed, they cannot treat more public patients without adequate public beds and facilities. "To say that more doctors will solve the problem is a myth," says Dr Michael O'Keeffe. "Ten years ago, there were 12 A&E consultants, today there are 49. Is it any more efficient? The US is flooded with doctors. Has that solved their problem?"
Dr O'Keeffe, known for his 5.30am starts, probably works 70 to 80 hours a week between his private and public practice. "Brendan Drumm [ chief executive of the HSE] seems to be the only person in the world who thinks we don't need more beds. The only reason I can't do more in the public system is because I haven't the facilities. This week I would have done two more cataracts in the public system if I'd had the facilities. Instead, those patients will go on the NTPF [ National Treatment Purchase Fund] list and get it done in the private system and the State pays everyone. This is why private clinics are mushrooming, and more and more doctors are going massively into debt to build private hospitals because that's where they see the future. The balance is going all wrong.
'THE NAME OF the game for the HSE is control. Stuff the doctors' mouths with money and take control in exchange. It's true that doctors like money but control is only a fraction of the problem. You have to start at hospital level. You have to get the manager out of his office. He should be scrutinising your lists, asking how come your list was cancelled on Tuesday, or why you saw only half the number of patients or why that operation didn't start at 8am. It doesn't happen. It should have, on foot of the last contract. But I've yet to have a secretary manager come to my clinic. Never happens. If you come up with an initiative, it's buried. I'm not holding up the system. We could do huge reforms. But it's on the ground floor that we need it".
The argument that the new contract would "gag" consultants ran out of steam - and removed a major plank of the IHCA's objections - when the HSE diluted that clause.
According to Dr Keaveny, the consultants agreed to extended working hours, to clinical directors, and to working in teams. They had a difficulty with being asked to treat weekend days as weekdays but will agree to certain sessions. They also quibbled with a working day of 7am to 10pm: "We felt 8am to 8pm was reasonable. We also wanted something in the contract that guaranteed the tools and resources to work with - which they said they couldn't guarantee. In the whole process, money was never mentioned until the last day, on April 5th, and that was only because the chairman said they had to put a price on it. We have never commented on the salary and whether it was acceptable."
He remains insistent that unless the top consultants are allowed the "bonus which is private practice", they will not come. "Why would they come back to a sector where hours and income are totally controlled? Our sole interest is to get the best people working here . . . We strongly believe that once you've fulfilled your 39 hours - and we have no difficult being monitored in that respect - you should be free to see private patients in a different hospital if you so wish."
He mentions a danger of creating two tiers of consultant, of splitting the public and private systems, so that the rich will have access to whichever suits and the poor will not. "Everything is being privatised but there is no expansion of the public sector. Local A&Es are not being expanded. Co-location is farcical and is possibly dead."
Clearly, despite the common ground achieved in these negotiations, divisions have grown amid a sense of disrespect from the other side and that some sharp practice has taken place. "We were told there would be a pay-related bonus but were never told that it would be 20 per cent".
There is a question of tone, a certain dismissiveness, to which the consultants are not accustomed. "They are difficult, tense, demeaning", says Dr Keaveny. "There doesn't seem to be the will to cede anything we suggest. They only ceded on advocacy because Niamh Brennan [ who recently chaired the Commission on Financial Management and Control Systems in the Health Service] was pilloried on radio."
Who will blink first?