Consultants have clinical responsibility but not the authority to direct resources, writes Dr Colm Quigley
It looks as if long-needed reforms in the health service are to be grasped by the Government. It is regrettable that one of the recent reports should have contained so many inaccuracies on points of fact.
The Report of the Commission on Financial Management and Control Systems in the Health Service (The Brennan Report) rightly argues that accountability for spending should be devolved to the lowest and most appropriate decision-making level. It goes on to state that the general-hospital sector accounts for almost 50 per cent of national health expenditure and that the commission considers consultants to be the key decision-makers affecting expenditure in hospitals.
This is not correct. Consultants have all of the clinical responsibility for patients but without the authority either to spend money, open extra beds when needed, extend outpatient clinics or employ extra staff.
Over 70 per cent of hospital expenditure is devoted to wages and salaries. Of the remaining 30 per cent, a significant proportion is spent on heating, lighting, communications, catering, travel and subsistence and other fixed overheads. The only area where a consultant has a discretion regarding spending is in the ordering of tests, procedures and prescribing drugs.
In a limited number of instances, a consultant may have a choice between a cheaper generic drug and more expensive branded drug for a patient. There is no evidence to support the theory that consultants are not cost-conscious when ordering tests or prescribing drugs.
I am much more concerned at statements from the Ministers for Health and Finance that structural reform will not lead to a reduced number of staff involved in management and administration.
The number of people employed in the health services has grown from 68,000 to 96,000 over a six-year period. We have not had a sufficient increase in the number of medical personnel - only the increased burden of a bureaucracy that is breeding further bureaucracy.
The report shows scant understanding of how consultants actually spend their working day. Anybody who has had direct experience of hospital life knows that a consultant's working day stretches from early morning to late evening.
We have about 1,500 consultants appointed to our public hospitals. It should be noted that each and every consultant appointment has to be cleared by the Department of Health before being advertised. There are over 2,500 admissions to our acute hospitals every day, seven days a week. In excess of 1,000 outpatient appointments per hour, 40 hours a week, are made with hospital consultants.
In addition, there are about 1.2 million attendances at our A&E units annually.
How can 1,200 admitting consultants devolve a personal service to each and every one of these patients? It must also be remembered that 70 per cent of admissions to our hospitals are emergencies. They receive priority treatment irrespective of their status as public or private patients.
Of necessity, consultants delegate aspects of the management of patients to colleagues, NCHDs, nurses, physiotherapists, cardiac technicians, laboratory staff and others.
It is not humanly possible either in terms of time or expertise for a single consultant to provide every aspect of a patient's treatment requirements.
This applies to all patients, irrespective of their being public or private, and is internationally accepted practice.
To suggest that delegation of duties arises only in the case of public patients is a grossly unfair accusation. If it were even remotely true, consultants would be breaching the Medical Council's ethical guidelines, their contractual obligations, and their obligations to their patients admitted under their care.
The Irish Hospital Consultants' Association has repeatedly stated that we are open to any set of proposals regarding amendments to the current contract. We will discuss proposals regarding consultants treating public patients only, contracts which confine consultants to public hospital only, or any other format of contract that may be devised.
Our one stipulation is that whichever form of contract is eventually agreed, should be available to all consultants and we will resist any proposal that a particular type of contract should be, for example, mandatory on new appointees. Would any other representative organisation take a different stance?
Emergency patients, be they public or private, are prioritised in accordance with their medical condition. They are accommodated in the first available bed, irrespective of the category of bed or patient. The mayhem in our A&E units does not arise because of any two-tier system. It arises simply because we have the same capacity in A&E today as we had a quarter of a century ago. Increasing the number of emergency medicine consultants by 200 per cent or 300 per cent would be a great help.
It is not the consultants who make the rules.
The Department of Health and hospitals decide on the number of beds available to patients on any given day. They also decide on the number of public and private beds in each and every hospital.
Thus, other than for emergencies, the number of private admissions is governed by Department of Health and hospital regulations. Every patient, without exception, is categorised on admission as public or private. There should be no difficulty in quantifying the volume of private practice engaged in by any consultant.
Despite working in excess of their contractual commitment consistently over the years, hospital consultants have been unfairly targeted by some as the scapegoats for all the ills in our hospital services.
When every other group has taken industrial action and disadvantaged patients in the short term, consultants have continued to look after their patients and done their best to make up for the gaps in services created by those who have gone on work-to-rule and on strike.
Structural reform and the proper deployment of resources are the priorities for the health services. We are very keen to sit down with those charged with managing our health services to implement reform. My abiding concern is that when we have a revised contract for consultants, the problems of our health services, and our hospitals in particular, will continue because of a failure to address the challenges of reform, funding and accountability.
Dr Colm Quigley is president of the Irish Hospital Consultants' Association and is also Consultant Physician at Wexford General Hospital