Politics

Public-only consultant contracts: is the health system finally beginning to see some benefits?

Much staff opposition has fallen away and uptake is higher than had been predicted, though it seems clear the outgoing Minister is not content with the pace of change

Chief executive of the HSE Bernard Gloster and outgoing Minister for Health Stephen Donnelly. Photograph: Brendan Gleeson
Chief executive of the HSE Bernard Gloster and outgoing Minister for Health Stephen Donnelly. Photograph: Brendan Gleeson
Shauna Bowers's picture
Shauna Bowers
Thu Jan 09 2025 - 06:00

In negotiations around the public-only consultant contract, tensions were high. The proposed change was an important part of the State’s move towards its Sláintecare goals, according to those in the Department of Health and the HSE, but there was significant opposition from staff unions.

Under the public-only consultant contract, consultants can be asked to work 8am-10pm Monday to Friday and 8am-6pm Saturday as part of their core 37-hour week. Any private work they do has to take place outside their rostered hours, away from the public facility.

Basic pay under the contract ranges from €217,325 to €261,051 on a six-point scale, with additional pay for on-call duties and overtime, and supports for medical education training and research.

At the time, the Irish Hospital Consultants’ Association (IHCA) said it did not think many consultants would take up the new contract. At the same time, members of the Irish Medical Organisation (IMO) rejected the new contract, with 57 per cent of current contract holders indicating they would not switch to the new contract.

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But now, 21 months after its implementation in March 2023, 60 per cent of consultants have signed up to the contract.

[ Public hospitals made almost €390m from private patients last year ]

Gabrielle Colleran, president of the IHCA, said the numbers of consultants signing up to the contract “speak for themselves”.

“What that says to me, is for a large number of our members, the contract represents an improvement. I think with balance and looking at how things are evolving, it does represent progress, the new contract,” she says.

“And that’s crucial in terms of meeting the challenge of recruitment and retention of consultants. It’s definitely working with attracting people.”

By February, almost a year since its implementation, there was a clear geographical divide in the uptake of the contract. The midwest, which represents Clare, Limerick and North Tipperary, had a significantly lower uptake than those in the other health regions around the State.

More recent figures, from the end of November, show that while uptake in the midwest is still lower than many other areas, it has increased significantly in the months since.

Ms Colleran said an “educated guess” as to why this situation has arisen is due to a “lack of trust” between consultants and senior executives in the region.

Given the extra cost to the exchequer, are we beginning to see the benefits of the contract? Last February, concerns were raised that though consultants were taking up the contract, the activity the department hoped to achieve wasn’t necessarily being seen.

Data shared between the department and the HSE, obtained through Freedom of Information, found that in the Mater hospital there were 112 consultants on the new contract, though none were rostered outside 9am-5pm or on Sunday. In St Vincent’s hospital, 69 were on the new contract, with 48 of those rostered outside 9am-5pm, and 11 rostered on Saturday.

In Tallaght University Hospital, there were 67.5 on the new contract, with none rostered outside core 9am-5pm hours or on Saturdays.

However, this has improved since. The Mater said there were now 273 consultants on the contract, all of whom were “committed to working on Saturdays”. In Tallaght hospital, in May, there were 102.75 on the new contract, of which 70 worked outside of core hours and 14.5 on Saturdays.

The HSE wrote to hospitals expressing concern that the benefit was not being seen for the investment that had been put in. But sometimes there were reasons for this.

In an email from Anne Marie Hoey, the national director of HR at the HSE, to the department in February said the “flexibilities in the contract must be considered in the context of the overall needs of services”.

“There are certain specialities in an acute hospital where the benefits are evident to patient flow, including EM [emergency medicine], radiology, medicine, etc,” she said.

“Other specialities may not benefit to the same extent and must be considered against the impact of two rest days during the week for those who may work on Saturdays.”

Over time, as long as we get the recruitment bit right so we have enough staff to do it, I think it will be quite positive

Outgoing Minister for Health Stephen Donnelly has written to the HSE on a number of occasions seeking details on rostering – whether these consultants on the new contract were working evenings and weekends.

Donnelly attended a meeting of the board of the HSE in May, and raised concerns the “impact on working practices and activity at site level has been challenging to quantify and there is a need to see that the increased capacity, which has now been funded, appearing in the number of clinical sessions made available”.

In a letter to the HSE that same month, Donnelly wrote that it was important there was transparency around the benefits use of the contract.

“Based on additional data (by speciality) which I have received, there are stark variations between the number of outpatient appointments being seen by consultants (same speciality) at different hospitals. In some cases, there may well be very valid reasons for this,” he wrote.

“The importance of comparative data is to identify areas that require analysis and improvement. It will then be the responsibility of local management/leadership and clinical services to identify the root cause and correct it.”

This is one of the challenges identified by the IHCA, too. Consultants should be viewed as “part of the puzzle”, says Colleran, when it comes to increasing scheduled care at weekends.

“Right now, if you were to add me in on a Saturday (instead of during the week), I wouldn’t get as much done because I wouldn’t have the other staff with the Saturday contract in place as I would on a Monday, so that bit is still in progress,” she said.

“Over time, as long as we get the recruitment bit right so we have enough staff to do it, I think it will be quite positive.”

Bernard Gloster, chief executive of the HSE, told the board of the executive that the Minister mandated a new control on consultant recruitment, and that posts would “only be approved if productivity compared to 2019 levels can be demonstrated”, according to minutes of the meeting.

It seems clear, from the repeated interventions by the Minister, that the pace of change is not quite as fast as he would have liked.

The other aspect of the contract was around private care, but it will be another while before the impact on that is seen.

Consultants who are transferring to the new contract have had to wind down the private care they provide. New consultants who are recruited on to the contract will not be undertaking any private work, unless it is in their own time and not at a public hospital facility.

Under previous contracts, consultants were allowed to spend 20 per cent of their time on private patients. The elimination of this means these consultants will have more time – seven hours based on a 35-hour week – to treat public patients, thus reducing waiting lists.

Though it is fairly early days, waiting lists are coming down. If things continue on this trajectory, it appears the contract could prove to be a positive addition to the health service.