There is tentative hope that a new consultants' contract could be agreed next week, writes Martin Wall, Industry Correspondent
When health service management and medical organisations meet again on Tuesday, it should become quickly apparent whether they are on the threshold of an agreement that could change the landscape of hospital practice in Ireland, or are about to embark on a potentially bitter and protracted industrial dispute.
After a series of stop-start negotiations which have dragged on for years, the parties face three more days of intensive talks aimed at securing the holy grail that successive ministers for health have long sought - a revised contract for hospital consultants.
For the Government, the importance of securing this deal cannot be overstated. Virtually all the main changes it wishes to put in place - having hospitals operate over an extended working day, having senior clinical decision-makers on site more of the time, the establishment of better provision for discharging patients at weekends, the introduction of greater clarity on the treatment of private patients in public institutions, etc - will flow from this one, elusive document.
The mood music between health service management, the Irish Hospital Consultants Association (IHCA) and the Irish Medical Organisation (IMO) is better on this occasion than has been the case for some time. It seems that the parties are genuinely working positively to secure an agreement.
However, very serious potential obstacles remain, including pay, hours and private practice rights. It would be foolhardy to predict that we will see the Minister for Health, Mary Harney, and consultants' organisations shaking hands on a deal within the next few days.
It is generally believed that the common contract for hospital consultants, first negotiated by the then minister for health, Charles Haughey, in the late 1970s, represented one of the best deals ever secured by any public sector group.
Management sources have said that the contract created a unique creature - the public service entrepreneur. They maintain that it allowed consultants to have all the benefits of a public service position - good salary, pension, secure employment etc - while being able to use the employer's premises, equipment and staff to operate a private business for their own advantage.
And, with rapidly increasing numbers of people covered by health insurance, the private healthcare market is booming. Last year the VHI alone paid out €237 million to medical consultants.
Under the basic terms of the contract, which have essentially remained the same over the last 30 years, consultants work a net 33 hours a week in public hospitals. Around one-third of consultants have the right to treat fee-paying patients in off-site private hospitals, while the remainder can treat private patients in their public hospital.
Around 20 per cent of beds in public hospitals are reserved for fee-paying patients - a move which generates revenue for both consultants and hospitals.
Consultants also enjoy clinical autonomy and are not held accountable for the resources spent as a result of their clinical decisions.
Also, under existing arrangements, many public patients are not treated directly by a consultant. Instead, consultants lead teams of non-consultant doctors who are training in their particular specialty.
The need for change has been identified for years. Nearly 15 years ago the move to a consultant-provided system where everyone would be treated by a consultant was adopted as Department of Health policy.
However the pace of implementing change has been glacial. In the mid-1990s, the then minister for health, Michael Noonan, warned that "no change was not an option". However, for the next decade, no change was precisely what happened. The need to introduce radical changes to the contract was discussed at senior political level in the run-up to the Government's health strategy in 2001, but was eventually ducked.
The most recent impetus for revising the existing structures stemmed from the Government healthcare reform documents published in 2003. One of these documents, the Brennan Commission Report, was particularly critical of the consultants' contract.
The chairwoman of the group, Prof Niamh Brennan of UCD, highlighted "shocking" weaknesses in the contract. She said its terms were so loosely drawn that it allowed consultants to delegate their contractual duties to other staff. The report urged that new consultants should work only in the public sector.
A second blueprint, the controversial Hanly report, recommended that the overall number of consultants be increased to 3,600 to ensure that all patients would be treated by fully-trained consultants. However the Government insisted that these additional 1,600 consultants could be recruited only on revised terms and conditions.
Talks on a revised contract got underway in November 2005 but quickly ground to a halt and have stopped and started ever since. Management sources have contended privately that the aim of the medical organisations was to play for time as much as possible in the knowledge that any new contract could not be as good as the existing one. The same sources argued that the consultants sought to run down the clock until the general election in the hope that any successor to Mary Harney would agree to more favourable terms.
For their part, the consultants maintain that many of the delays were due to the management side not being able to agree internally on what it actually wanted. Health service management is not a single unitary body. There are at least half a dozen groups, such as the senior officials in the Health Service Executive (HSE), the special advisory team to its chief executive, Prof Brendan Drumm, the politically-appointed governing board of the HSE, senior officials in the Department of Health, the special advisors to the Minister, the voluntary hospitals and the Department of Finance. All have an input into the position of health service management. And not all these groups have identical interests and aspirations all the time. Consultants argue that on some occasions negotiations were cancelled because the management side had no agreed proposals to put forward.
Essentially, next week will see tough negotiations on management proposals that consultants in public hospitals should in future have either very restricted or no rights to private practice as well as on issues such as pay and hours of work. Management has proposed that consultants should work as part of teams over an extended day and that weekend duties would be part of the normal roster - although there are indications that it may be moving away from the latter position.
Management has offered salaries of up to €205,000, plus potential bonuses of up to 20 per cent.
The plans to restrict private practice rights will not affect only public hospitals. The move could have significant implications for existing private hospitals and for the new facilities currently being developed on foot of Government tax breaks.
While the Government cannot break the existing contracts of consultants, no additional doctors would be appointed with rights to treat patients in off-site private hospitals. The Department of Health has said that it is a matter for private hospitals themselves to source consultant staff. However medical organisations have warned that in some specialties there may be too few patients in private hospitals to justify the appointment of full-time private consultants.
And, even where such positions were viable, hospitals may have to recruit abroad for doctors to fill these posts. Any private practice restriction is an issue which the private hospital sector, already facing the prospect of coming under a new State licensing system, will have to examine carefully.
There is also some uncertainty about how the Government's plans for co-located private hospitals on the grounds of public institutions would be affected by the proposed private practice restrictions. The Department of Health is this weekend preparing answers to a series of questions on this issue for the talks next week.
The endgame has been forecast, inaccurately, in this process on many occasions in the past. However, it does seem that the current negotiations are nearing their end. By next weekend the heads of agreement on a new contract may be signed which would not only change public hospital practice but have major implications for private hospitals.
However, if the talks collapse, the Government seems certain to introduce a new contract unilaterally - a move that will plunge the hospital sector into a major industrial dispute with one of the most powerful groups in the country.
Patients, patients consultants' fees
There are 2,144 public hospital consultants in the country. Around one-third of these hold what are known as category II posts, which allow them to treat fee-paying patients in off-site private hospitals.
Two-thirds have category I posts, which allow them to treat fee-paying patients in their public hospital.
Some 20 per cent of beds in public hospitals are reserved for private patients. The current official ratio of public to private work carried out in public hospitals is 83/27. However, in some hospitals the number of private patients treated is closer to 40 per cent.
Salaries for category I consultants range from 164,181 to 181, 998, depending on the part of the country they work in. Pay scales for category II consultants range from 146,613 to 162,455, depending on location. Academic consultants and the masters of maternity hospitals can earn up to 234,000.
Private practice earnings depend on the specialty of the consultant and their location.
The insurance companies do not publish details of payments to individual consultants.
Last year, VHI, which has just under 80 per cent of the market, paid out 237 million to medical consultants.
Consultants in specialties such as paediatrics, geriatrics or psychiatry are not believed to enjoy widespread private practice.
MW