The shadow of a contract  

Chair of the IMO consultant committee Dr Matthew Sadlier writes that there are still lingering questions to answer about the implementation of the new consultant contract

“I can’t stand this indecision

Married with a lack of vision”

Everybody Wants to Rule the World Tears for Fears

From the perspective of the IMO consultant committee, 2023 was always going to be a year of watching, waiting, and reacting.

The public-only consultant contract (either referred to as ‘POCC’ or ‘Pock’ depending on preference) being agreed just prior to the 2023 AGM cast a long shadow over the year. Would the number applying for consultant posts increase? How many existing consultants would move over and what effect would this have? These were the main questions that we were left with when the contract was introduced.

Recent data from the Department of Health has given us some answers. It showed that 1,900 (45 per cent) consultants in total, of which 1,543 are existing consultants, have signed the new contract. This is roughly in line with the ballot conducted by the IMO at the time of the contract’s release. The Department statement further reported that uptake was strong across all specialties and that this will have an “increasingly positive impact upon the delivery of healthcare in Ireland”.

Unfortunately, these answers just lead to more questions. While consultant recruitment and retention has been one of the barriers to the delivery of healthcare, it certainly has not been the only one, as this year has consistently shown. The crowding of our emergency departments with admitted patients awaiting beds has gone from a seasonal to a whole-year-round crisis. As I write this article, surgery is being cancelled across the mid-west due to this issue (in March which, last time I checked, is not winter). Will the POCC solve this problem? It won’t and it can’t because it actually doesn’t attack the root causes.

Narrative

There has been a consistent narrative, as long as I have been involved in medical politics, that the two evils affecting our hospital system are private patients and lack of timely discharges. What we have repeatedly heard is that the POCC, by providing additional consultant on-site presence and providing care solely for public patients, will obviously address this and all the problems in the hospital system will be solved. 

In regards to the first of these issues – the number of consultants – given that Ireland was starting from such a low base of consultants per head of population, increasing the number is only getting us somewhere near normal. Providing more available hours in the week will only be effective if it is accompanied by a similar increase in nursing, allied healthcare, diagnostic, and administrative staff. It might have escaped the policymakers’ notice, but the vast majority of consultants already work weekends and long into the evenings on on-call rotas. At these times, it is extremely difficult for consultants to access supports and services until ‘normal’ hours resume. This is quite apart from the ongoing difficulties in accessing theatres, diagnostics, and the myriad of other services that may be required for patients.

Funding

The Minster for Health’s recent comment that the POCC will see “many consultants wind down and cease private practice in public hospitals” and “hospital managers and clinical directors must ensure this additional capacity is used to improve access for public patients” really needs interrogation. Unless some dramatic change is coming in healthcare eligibility, those that have private cover are also entitled to treatment on a public basis in public hospitals. Given that the vast majority of all admissions to hospitals come via the emergency department, most of the patients that have heretofore been designated as “private patients” are now just going to be treated in the same hospital, in the same bed, by the same doctor, but as a “public patient”. The only difference will be the hospital will get less financial support to treat the patient. It will be critical that the Department of Health and the HSE show exactly how that funding is being replaced through additional State funding.

The continuing focus on these two factors are more ideological than practical and, in my opinion, will not solve emergency department crowding or improve care. Firstly, an excessive focus on discharge rather than clinical care and recovery is not a recipe for successful healthcare and often leads to repeat admissions. In my view, if we are serious in addressing our current difficulties there are some measures that cannot be avoided. That list of measures includes, but is not limited to, increased bed capacity of at least 5,000 beds; increased staffing across all disciplines; ensuring that new legislative and regulatory requirements (such as Assisted Decision-Making Act, open disclosure, etc) are resourced prior to their roll-out; and that each medical innovation is matched with adequate staffing. Rational staffing levels, especially for community-delivered services, must take into account issues, such as travel time and other factors, that reduce working hours during the week, and ensure each healthcare facility has access to childcare, after-school facilities, and canteens that match the working hours of staff. 

Loss

For the IMO, and indeed the wider medical community, the past 12 months have been overshadowed by the sad loss of Prof Sean Tierney in July. Sean had been a continual presence within the Organisation over the past 20 years and had been an active and invaluable member of the committee and the negotiating team all the way up until the final sessions in December 2022 and continued to work on the contract drafting and member information in early 2023. Sean had an incredible ability to both describe complex issues in very straightforward language while never losing sight of the main goals. Often as we would get stuck in “analysis paralysis”, it was Sean that would reorientate everyone towards what we were trying to achieve. 

During negotiations there is actually a lot of down time spent in the company of your negotiating colleagues in between plenary sessions. It was during these times that one fully appreciated the breadth of both Sean’s knowledge and personality. There was literally no topic on which he did not have a well-informed and considered opinion, which he invariably delivered with his trademark humour. Sean was a great example of George Bernard Shaw’s motto that if you are going to tell someone the truth you need to make them laugh at the same time. We will miss him.

In September, we also lost two other former consultant Presidents: Dr Phelim Donnelly and Prof Hugh Bredin. Both from the perspective of the IMO and Irish medicine in general, we owe a great debt to Dr Donnelly and Prof Bredin, who were prepared to unstintingly sacrifice long hours to ensure that their colleagues were in a better position to help their patients. It is both our responsibility and our challenge to ensure that we continue to reach the high standards that they set and that they always met.

As we gather for our AGM, the fundamental problems that beset our health services remain unresolved: Too few doctors, insufficient capacity, and no funded workforce plan.