Hospital consultants will shortly embark on negotiations with their employers which will determine how patients are treated in Irish hospitals in the future.
The long-expected and comprehensively leaked report of the Medical Manpower Forum will go to Cabinet in the next few weeks. Once it is published, the next phase in the battle for health-service reform will take place in talks with the medical organisations about a new consultants' contract.
Already the medical organisations have scored one victory in the forum. This is the shelving of proposals - supported by the Department of Health, the health boards and other employing bodies - to introduce a category of consultant with a contract designed to ensure rostered availability to public patients.
The final version of the report notes that this option is "not acceptable to the medical organisations". Instead the forum has adopted as its "preferred option" the negotiation of a revised contract for all consultants which would provide changed work patterns, flexible rostering and clinicians working together in teams.
It is perhaps significant that the forum report records but does not endorse the medical bodies' rejection of the so-called "Category 3 consultant" option. Presumably, were the talks to fail to deliver the reform package sought by the Department, Category 3 could yet be revived as a proposal.
Concrete change will only come and can only be judged when the new consultants' contract is open to inspection. However, the forum's report represents a significant milestone in the acceptance by all parties of a disturbing picture of the current medical system and of the absolute necessity for change.
The forum was set up in 1998 by the then minister for health, Mr Cowen, in response to medical manpower problems in hospitals, with the brief to suggest career structures which would retain Irish graduates and deliver better medical care. It brought together representatives of the medical profession and health administrators. All these people accept there is "inappropriate staffing" of hospitals and "limited availability of senior clinical decision-making".
"Frontline services are mainly provided by non-consultant hospital doctors, many of whom are in the early stages of their training or not in formal training posts. Long waiting times, additional tests, referrals to other junior doctors and a reluctance to seek senior opinion at times have serious implications for both diagnosis and treatment of the patient," the report states.
From a medical system which depends largely on junior doctors in poorly-supervised training, a third of whom are not Irish, and which exports large numbers of medical graduates, the forum aims to develop a system in which public patients receive care from fully trained doctors and which retains Irish medical graduates in an attractive career structure.
Delivering this service necessitates the creation of many more consultant posts, but it is apparent this is contingent on the agreement of an acceptable new consultants' contract.
The Association of Hospital Chief Executives noted in its submission to the forum that simply increasing consultant numbers without a revised contract "would not achieve significant improvements in public patients being diagnosed and treated by fully trained doctors".
The report accepts as a given the two-tier nature of the Irish health system, recognising "a mix of public and private hospital services as Government policy", but it states that as a basic principle "all patients should have equal access to hospital medical services". Examining the contradiction between these two positions was not part of the forum's brief.
Two Opposition political parties are now committed to addressing the two-tier system. First the Labour Party and then Fine Gael proposed bringing in a comprehensive health insurance system in which the Government would pay the premiums of those who cannot afford to do so.
In the Labour proposals it is clear that this would, in effect, remove traditionally understood private practice from public hospitals, with all patients in the State health system covered by private health insurance and with equal access to services.
As an ESRI economist, Prof Brian Nolan, pointed out on this page last month, there are other routes to this objective without involving private insurance companies. Equal access to State hospital care could also be ensured through a social insurance system, or with direct State funding.
The introduction of a comprehensive and equitable healthcare system is now a central political issue in what could well be an election year. Pressure is mounting on the Government to come forward with its proposals. The Department of Health is working on a new health strategy document to succeed Shaping A Healthier Future, which was the product of the Labour Party's Mr Brendan Howlin's tenure as minister.
Negotiations on a new consultants' contract will take place against this backdrop. Consultants now work in a system where they are salaried for treating public patients - 55 per cent of the population - and paid for each service delivered to private patients - 45 per cent of the population. Most consultants work in a balancing act in which they receive income from both sources, a balance which makes it more likely that they will personally treat private patients.
Should the Government find it politically necessary to convert to more radical proposals for health-service change, or should an election and change of government overtake the consultants' negotiations, then the medical organisations might be facing not only proposals for changed work patterns but also for a different system of remuneration.
They might favour the extension of fee-for-service to all their patients. However, they could well be offered substantially increased public salaries in return for an end both to combining public and private practice and to their status as part salaried, part self-employed.
Politicians of all hues realise that to remove the distinction between public and private patients in public hospitals will only be politically possible if the public health system is very much improved. Ensuring consultant-provided care in public hospitals would be a central part of any party's reform package. Clearly, it cannot come alone.
Acceptable public hospital services also require a continued commitment to sizeable increases in health spending to provide more beds, upgrade facilities and address staffing shortages and rostered availability in all the ancillary areas, particularly nursing.
As the medical organisations never fail to point out, maintaining round-the-clock services in our present dispersed hospital network would entail absurd duplication and impractical expenditures. Continuing to centralise regional specialist services is a sine qua non for improving healthcare.
The Medical Manpower Forum is not the first body to paint a dismal picture of the Irish medical system. The Tierney report of 1993 portrayed exactly the same shortcomings. This time, however, the medical organisations have signed off on the need for change, the public demands it and the money is there to effect it. The pressure on the Department, the IHCA and the IMO to deliver will be immense.