The dispute involving Dr Colman Muldoon, consultant physician at Our Lady of Lourdes Hospital in Drogheda, and the North Eastern Health Board is rooted in the tension between clinical independence and accountability in the health services.
Dr Muldoon, a physician of the old school, has provided care to the people of Drogheda and its environs for almost 30 years. The appearance of 1,000 people at a rally in the town last weekend and the evidence of 10,000 signatures on a petition of support suggest a substantial cohort of satisfied patients and their families.
When Dr Muldoon commenced practice as a consultant physician in the 1970s, the health service was a vastly different environment to that which exists in the early days of the 21st century. The Medical Missionaries of Mary ran the hospital, with no day-to-day involvement by the health board. The environment would have been one of leadership from the top - a leadership supplied by a handful of consultants and religious administrators.
In the health service of the time, entire hospital wards were often allocated to specific consultants and administered by a religious ward sister. Between them, the consultant and the sister had huge autonomy in the running of their particular part of the hospital. Decisions as to the admission of patients and their length of stay would have been made at ward level, without the involvement of hospital administrators as is the case today.
In addition, patients stayed longer in hospital - the role of bed rest and a limited range of treatments saw to that. Following a heart attack, patients would have remained in hospital for weeks. The removal of a gall bladder, which would have necessitated a stay of about two weeks, now merits a couple of days following the introduction of minimally invasive surgical techniques.
The evolution of treatment options in medicine has been matched by a huge increase in the infrastructural aspects of medical institutions. There is now a significant planning, financial and administrative body to match the front-line care-givers.
It is the duty of hospital administrators to plan their service on a yearly basis. Apart from determining how many operations and other procedures will be performed during the coming year, this service plan also forms the basis for funding requests to health boards and the Department of Health.
It is the hospital service plan, and Dr Muldoon's own practice plan in particular, which has directly led to the dispute and the placing of the consultant on mandatory administrative leave. The latter is a mechanism of paid suspension provided for under the Consultants' Common Contract, which is the legal basis under which hospital consultants are employed in the State.
Dr Muldoon maintains that the sanction of administrative leave should be used only where there is an immediate risk to the safety, health or welfare of patients. He has also referred to a clause in the contract specifying the clinical independence of consultants. The hospital, on the other hand, points out that an individual doctor's right to clinical autonomy cannot be exercised without due regard to the rights of other doctors and their patients. It presumably sees Dr Muldoon's inability to agree a practice plan as jeopardising the overall financing of the hospital.
Mr Justice O Caoimh came down on the side of the hospital in the High Court. He also ordered a review of Dr Muldoon's clinical practice by an independent group of doctors from the Royal College of Physicians, which will focus on why the length of stay of his patients was significantly above the national average.
So where does this leave Dr Muldoon's patients and indeed what are the implications for health services in general?
Dr Muldoon continues to practise privately. However, he is precluded from entering the hospital. In theory at least, should Dr Muldoon wish to admit one of his private patients, he will be unable to do so. The health board will have made arrangements for Dr Muldoon's public patients to be looked after by other consultants at the hospital.
The general ramifications of the case are quite significant. It focuses attention on the reasons why one patient may spend longer in hospital than another with a similar diagnosis. The most obvious reason is that patients are people and not machines and that under a particular diagnostic label lies a myriad of differences which will impinge on that person's progress during hospital treatment. Other factors include the level of medical staffing, access to diagnostic services and whether the hospital operates as a specialist centre or not.
Questions must also be asked as to the role of the Department of Health in the planning of healthcare. The Department operates a system of case-mix penalties in which individual hospitals can be financially penalised for excessive length of stay. This can hamper future service development which will ultimately impact negatively on patient care.
The Muldoon/NEHB case demonstrates the need for more finely tuned measures of health service performance. Outcomes such as quality of life and patient satisfaction are surely as important as bed utilisation. It also highlights the current shortage of community-based services with which to support patients on their early discharge.
Ultimately, however, the controversy signals the end of an older style of hospital care and its replacement by an environment in which doctors must work within a system of both clinical and administrative accountability.