Real leadership within our hospitals is needed to transform the health services we provide. Prof John Higgins argues that consultants must lead the change
At the level of remuneration we receive as consultants we would be in senior management roles in any large commercial organisation and would be expected to bring to the organisation, initiative, strategic thinking and, most importantly, problem-solving. Simply identifying problems or defining problems would not be acceptable.
The public are now desperate for solutions. Consultants must become and be clearly identified by the public as being problem-solvers. It is with this problem- solving philosophy in mind that I wish to address three current issues:
- Configuring consultant contracts;
- Consultants in management, nurturing leadership;
- The "pursuit of excellence".
There are three essential elements needed in any new consultant contract - flexibility, flexibility and more flexibility! It is worth emphasising the idea of a new contract because it would be difficult to radically change the current contract holders who instead should be "parked" with the option to take up the new contract.
My views are strongly influenced by my experience working as a consultant in the Australian system (where hospital services are free but 40 per cent of the population have private health insurance). I suggest an alternate model for new contracts where the norm would be less time contracted to the public system but a public commitment which is more clearly defined.
The time commitment of my consultant colleagues in Australia to the public hospital system varied widely from as little as one session, ie a single clinic a week, to as much as 11 sessions. By far the most common options, however, was a four-five session arrangement.
This was very efficient for the public hospital system. It ensured the contribution of a large number of individual consultants to the aggregate expertise available to a hospital. As long as consultants fulfilled their obligation to the public hospital, no attempt was made to dictate what they did outside this time. If they so wished, it left them free to augment their income by doing sessions in other public hospitals or in private practice. It was a win win formula.
In Australia, the public hospital system remains the backbone upon which hospital services are arranged. It is the public hospital system which deals with the most complex cases. It is the public hospital system which continues to attract academic colleagues to drive research and innovation. It is the public hospital system which trains the next generation of practitioners.
In Ireland, multiple new contract options must be available. Being an obstetrician in Clonmel is completely different from being a gastro-enterologist in Dublin. Public hospitals must have the flexibility in the type of contracts they offer. There are several key principles which should be borne in mind while planning any new configuration:
- Treatment of a private patient by a consultant should enhance the opportunity of a public patients receiving treatment.
- The fundamental difference from a patient's point of view that I perceive between Australia and here is in terms of capacity; both public and private. By capacity, I don't simply mean bed numbers, for capacity is a mathematical combination between bed numbers and efficiency of use.
- Regardless of how good the public system becomes, if patients have an affordable choice, large numbers will avail of additional private cover.
- The obligations to the public health system of an individual consultant should be clearly understood.
- Private patients will always continue to be admitted to public hospitals. Private patients are taxpayers who have already made a significant contribution to their health system. They are exercising choice in how to spend their money and broadly they should be encouraged to do so.
Adapting an analogy used recently, private patients in the public hospital sector are like business class customers on aeroplanes except they already own the aeroplane and have paid for an economy seat but are willing almost to pay again for an upgrade in service. In fact, if there was only economy seats available they are willing to pay business class service in an economy seat. As long as there is at least one empty seat on the aeroplane, why, on principle, should we seek to deny choice?
In a country such as ours with a small population and a wide geographical spread if we try to lay down absolutes, then the mixed funding system will not work. There will be multiple unnecessary bottlenecks.
The three key components of any new consultant contract are also the three key components needed across our entire hospital system: public and private, ie flexibility, flexibility, and more flexibility. If dynamic flexible arrangements are put in place then I think the planned co-location model could be an absolute winner.
Nurturing leadership is a vital component of any successful organisation. Irish hospitals have slowly been developing clinical directorates, ie distinct clinical services with a defined budget with a consultant as head of the directorate. It is time to enhance radically the scope of this process.
I suggest that each hospital in Ireland should have an overall consultant clinical director who is appointed (not elected). The appointment should be time limited. The director should set the strategic direction for the hospital, co-ordinate the service planning for the hospital and, most importantly, control the overall budget. In my view, such a development will energise hospitals, large and small.
The appointment of clinical directors with real executive power will contribute hugely to an inclusive engagement between consultants and their own hospital. The acceptance of a leadership role brings with it responsibility, accountability and an acceptance of the financial impact of clinical decision-making.
It is this latter argument which originally catalysed the set-up of the clinical directorates and it is an inevitable extension of this logic that the hospitals themselves follow the same pattern.
For too long there has been a philosophy within the Irish hospital sector of "containment", of "survival" or of "avoiding pitfalls". Let's start to aim much higher. The pursuit of excellence, which is such an important part of consultant career development, must become part of the philosophy of the entire hospital sector.
Consultants bring unrivalled experience and knowledge of working in the very best hospitals in the world. I see no reason why we shouldn't have the best hospital system in the world. In my view, we already have the best consultants. Let us look to the future with ambition, energy and enthusiasm. Consultants must lead not be led. Consultants must lead the change agenda in the Irish hospital system.
- Prof John Higgins is professor of obstetrics and gynaecology at University College Cork.