More than three years ago, the then head of the Health Service Executive (HSE) Tony O'Brien warned Leo Varadkar – minister for health at the time – that the rules governing the level of private work senior doctors could carry out in public hospitals had become a "farce ".
A contract introduced in 2008 set limits of 20 per cent on the number of private patients most consultants in public hospitals could treat – although a figure of 30 per cent is permissible in some cases.
The contract essentially allows some consultants to see only public patients while others can see fee-paying patients in State-run or State-funded facilities up to the limits of 20 or 30 per cent. At the same time, a third cohort of specialist doctors have rights to also work in off-site private centres.
However, for years there have been allegations that restrictions on private practice were being widely breached.
In July 2017, the secretary general of the Department of Health wrote to the HSE "citing concerns that consultants may be exceeding their permitted level of private practice within the public hospital system and may be exceeding their offsite private practice rights or engaging in off-site private practice while being employed under a contract that does not permit any off-site private practice".
‘Immoral’ behaviour
Later that year, an RTÉ investigation maintained that some consultants were working far more in the private sector than officially allowed.
Minister for Health Simon Harris said the behaviour of some of the doctors highlighted in the RTÉ programme was "immoral, brazen and unfair". He instructed the HSE to put in place a more robust system of monitoring.
The first report under this new system showed while there were considerable breaches of the rules governing the mix of public-private patients, there were no incidents of doctors employed in the public system working in private clinics or hospitals in contravention of their contractual arrangements.
It also says that while 236 consultants – about 10 per cent of the total – were treating more private patients than permitted officially, they were not at fault as this was due to circumstances outside of their control.
It suggested such non-compliance was due to structural issues in how patients were admitted to hospitals.
The first report of the HSE to the Department of Health under the new monitoring system supported separate findings of the Comptroller and Auditor General last year that individual consultants had limited control over private practice activity levels.
‘Clinical priority’
The HSE found more than two-thirds of patients were admitted through hospital emergency departments while a further 18 per cent related to women receiving maternity services for which there was no private hospital care available in Ireland.
“These patients must be admitted and treated in order of clinical priority,” the report said. “Where there is a lack of access to facilities in the private sector such as maternity, transplant etc, this can result in higher numbers of patients opting for private care in the public system.”
The HSE appears to be saying that the rate of non-compliance with the official public-private mix ratios is due in part to the limitations on private hospital care for patients seeking some forms of treatment and the absence of private hospitals in some parts of the country.
It also has to be borne in mind that public hospitals are encouraged to get patients with private insurance to utilise this cover, as it generates income of about €300 million annually.
The Sláintecare reform plan proposed a way out of the rows over alleged breaches of private practice rules, suggesting that public hospitals should be for public patients only.
This proposal is strongly opposed by doctors and a review group is currently examining the removal of private practice from public acute hospitals.
