The consultants' contract with the State has shaped the inequitable system ofhospital care, Maev-Ann Wren, writes in the second of a series based onher new book
Hospital consultants are one of the barriers to reform of the healthcare system. While there are consultants who believe in and have lobbied for a more egalitarian system, their representative association is adamantly opposed to change.
What is more, Finbarr Fitzpatrick, secretary-general of the Irish Hospital Consultants Association (IHCA), in an interview with the author, has confidently predicted that the IHCA will defeat the Government's signalled intention to introduce a public-only, salaried contract for newly appointed consultants in their early years. The new contracts, announced in the 2001 Health Strategy, have yet to be pursued in contract negotiations.
Hospital consultants' insistence on their right to conduct private practice has been one of the consistent obstacles to reforming the inequitable Irish healthcare system. In 1974, consultants threatened industrial action and defeated the Labour minister for health, Brendan Corish's attempt to extend free hospital care to higher income groups, because this would have faced them with a future as salaried State employees.
In 1981, they secured from Charles Haughey's government a contract of employment which gave them the pensionable salaries of public-sector employees yet offered to all consultants a right to unlimited private practice, in public or private hospitals. Subsequent efforts to amend that contract to make them more answerable to hospital managements have had limited success.
In 1991 when a further Haughey government finally made hospital care free to all income groups, it simultaneously introduced a system of bed designation which guaranteed that patients who opted to pay private fees would have access to a specified number of hospital beds - typically 20 per cent of the total - and thereby ensured that hospital consultants would have a continued source of private fee income. This system persists to this day.
Rory O'Hanlon, the present Ceann Comhairle and former Fianna Fáil minister for health who was the system's architect, told the Dáil in 1991 that the two-tier system had "served the nation well". He still insists that "if people want to pay for their own medical treatment out of their own disposable income, that is their right".
Hospital consultants are not, therefore, solely responsible for the inequity of the Irish system. Governments have conspired to retain a system in which those with money can buy faster access and better care than those without. The National Economic and Social Forum in a report last year on equity of access to hospital care observed that "the Irish arrangement, where private practice is part of hospital consultants' public contracts and carried out within the public hospital, seems to be very unusual".
Comparing international models of care, the NESF found that most states did not provide private services in public hospitals. Even in Australia, where private patients are admitted to public hospitals, there is a single waiting list for elective surgery and patients are treated on the basis of clinical need. Irish practice remains "exceptional". "The scope for 'two tiers' in terms of access is much greater here than in ... our European Union partners."
The NESF expressed concern that the Health Strategy made no commitment to ensuring that all admissions to public hospitals should be in accordance with medical need. It recommended a common waiting list "at a minimum", restating the ignored central recommendation of the 1989 Commission on Health Funding. The Government received the NESF report prior to last year's election but only permitted its publication afterwards.
The UN's Committee on Economic, Social and Cultural Rights last year also recommended the introduction of a common waiting list, when it regretted the absence of a human rights framework in the strategy and urged the Government to embrace the principles of non-discrimination and equal access.
Finbarr Fitzpatrick has stated that consultants would not resist a common waiting list and insists that governments have failed to introduce one because they want private income for hospitals. "If Micheál Martin comes out in the morning and says there will be a common waiting list, what are we going to do about it? They want the bloody money. Why won't they be honest with people? The number of beds in any hospital and their designation as public or private is not decided by the consultant."
While there is justice in this claim, it remains the case that Fitzpatrick and his association will resist the removal of private practice rights. Fitzpatrick's bellicose insistence on consultants' right to private practice echoes a tradition of Irish medical politics which has intimidated departmental negotiators who favour change to ensure greater equity.
In private deliberations in 2001, disclosed under FOI, a Department of Health working group on the public/private mix observed that "any near-term measures that would attempt to unilaterally remove the right and extent of private practice is likely to be met with the strongest opposition. Amending the terms of the contract can only be achieved through a process of negotiation and agreement."
Officials were showing undue respect for the industrial muscle of consultants and according them too powerful a role in determining the shape of the service and proprietorship in a service, which rightfully belongs to the citizens of the State.
The working group members echoed their Departmental predecessors, who advised Labour minister for health, Barry Desmond, in 1984 in an unpublished draft Green Paper, seen by this author, that, if an extension of eligibility for hospital services were attempted, "strong opposition could be anticipated from the consultants who would probably see a threat to their incomes from private practice".
When, in 2001, a Department sub-group proposed that consultants should be given productivity targets for the treatment of public patients which, if not met, would trigger restrictions in their right to private practice, the full working group demurred. "Monitoring of waiting times with productivity targets for individual consultants may be too confrontational to engender co-operation with more strategic change in regard to equity," its report noted.
Consultants' terms of emploment are extraordinarily anomalous in the public sector. They are salaried and yet are private practitioners, with all the attitudes of the self-employed. Their independence - arrogance in some - presents huge challenges for hospital managers.
If Irish hospitals are badly run, it is chiefly because the outcome of years of stormy negotiations between consultants and the Department of Health has been a contract that does not make clear who is in charge. Although the first 1981 version of their contract stated that medical need should be the overall criterion for hospital admissions, it reassured consultants that "it is not intended that there should be an exact measurement of the time spent by you in discharging your contract". The effect was that the Department of Health was unable to ascertain the extent of private practice in public hospitals.
A 1991 version of the contract strangely dropped the reference to medical need as the criterion for admission, but attempted to make consultants more accountable to hospital managements, by the introduction of "practice plans" which never became a reality. The 1997 contract, still current in 2003, stipulates that the proportion of a consultant's on-site practice accounted for by private patients should reflect the proportion of designated private beds in the hospital. This would be subject to an ill-defined review which, in the words of the 2001 Department of Health working group, "has not been operative".
Although the contract additionally states that "it is important to ensure the co-existence ofpublic and private practice does not undermine the principle of equitable access", "there is no mechanism in place to monitor this in practice", according to the working group, which concluded that "changes to the current Common Contract are critical to improvement in the current equity situation".
It is an unwritten understanding of consultants' terms of employment that they attend personally to their private patients' care, while they may opt to delegate as much as they wish of their public patients' care. They receive their public salary for a 39-hour week (of which 6 hours are set aside for "episodic activities" like planning and meetings) yet their contract does not insist that for the remaining 33 salaried hours, they dedicate themselves to public patients.
On the contrary, under the terms of the contract, they may delegate the treatment of public patients for whom they are responsible to junior doctors, while they earn fees for the treatment of private patients. The current contract states: "The consultant may discharge this responsibility (for investigation and treatment) directly in a personal relationship with his patient, or, in the exercise of his clinical judgement, he may delegate aspects of the patient's care to other appropriate staff."
The consequence for public patients is that much of their care is delivered by inadequately trained and supervised junior doctors. To remedy this, to ensure that all patients receive their care from a fully trained doctor, the Hanly taskforce on medical staffing recommends in its unpublished report that there should be a substantial increase in consultant numbers.
To deliver this, I contend, will require a revision of their contract to ensure that consultants work for public patients on site in public hospitals and their earnings will have to be lower than consultants' current earnings from public and private practice. It is this which the IHCA is bound to resist.
James Deeny, the State's chief medical officer in the 1940s, who came closer than anyone has since to convincing the political establishment that Ireland should have an equitable national health service, later observed in his memoirs that politicians must work with doctors: "You cannot take them out and shoot them". But to achieve change in the interests of better health, politicians have often found that they must confront the power of organised medicine.
In Saskatchewan in the 1960s it took an airlift of strike-breaking doctors to achieve Canada's first provincial health insurance plan. While such extremes are to be avoided, a Government which believes in equity and quality in Irish public healthcare will have to reclaim ownership of the system from the medical profession.
Tomorrow: Untrained doctors in ill-equipped hospitals.
Maev-Ann Wren is author of Unhealthy State - Anatomy of a Sick Society, published this week. (New Island, €17.99)