Niamh Cahill reports on the fallout from the Government’s deal with private hospitals and how it divided consultants
As private consultants greeted with relief news that the State’s deal with private hospitals would cease at the end of June, HSE officials were reportedly shocked that the arrangement would not be extended.
According to sources, the HSE and others had sought an extension, at least until the end of the year, due to concerns about potential further surges in Covid-19 cases.
The announcement followed weeks of intense lobbying by private consultants seeking an end to the deal.
The hashtag #cancelthecontract gained momentum on social media as opposition to the arrangement mounted.
Negotiations on a new agreement with private hospitals to provide access to capacity, effective from July, are beginning between officials from the HSE and Private Hospitals Association (PHA).
Health experts have warned the public hospital system is already at capacity and cannot cope with a rise in Covid-19 cases.
What type of agreement and how much capacity will be secured remains to be seen, however.
The fallout from the controversial deal has been immense on many fronts.
A new Association representing the interests of private consultants has emerged, while the circumstances under which Vice President of the IHCA Dr Laura Durcan resigned has raised concerns about bullying within the profession.
More recently, the Beacon Hospital, Dublin, has reportedly left the PHA. Any negotiations will now be conducted between State officials and the hospital directly.
The deal
On 30 March, the PHA reached agreement with the HSE on the provision of public health services in private hospitals amid fears of an avalanche of Covid-19 cases in Ireland.
In its statement announcing the move, the PHA said it was undertaken in “the national interest”.
Essentially, the agreement included hospitals only. It was left to individual hospitals and unions to engage consultants to provide care.
The majority of consultants knew nothing of the deal until its official announcement and were immediately taken aback at the lack of consultation.
As details emerged, private consultants learned the temporary contract on offer was essentially ‘type A or nothing’ and many felt the contract was being imposed on them. Type A contracts are those which allow public-only work, while type B contracts allow a mixture of public and private work.
A type B contract was sought to allow for greater flexibility, but this was refused by the Department of Health.
An IMO circular to members in early April noted the HSE’s views around patient care arising from the deal.
“Continuity of care is a top priority and it is envisaged that all current patients who require ongoing care will remain under the care of the participating consultant as a public patient.
“Patients currently in treatment and in need of continued urgent care will not be charged for their care.
“Arrangements will be put in place, on a compassionate basis, to ensure that patients receiving drugs or other treatment that are not currently provided in the public system will continue on their treatment.”
Consultants, however, insisted that taking a type A contract did not allow them to look after existing patients.
Private consultants have referred to the debacle as a “lockout”. If they failed to sign up, they could not treat any patients at their place of work.
According to Secretary General of the IHCA Mr Martin Varley, a large number of private consultants undertook patient work on a pro bono basis until the bank holiday weekend in May, “when the provision for clinical indemnity for them in that respect was removed,” he told the Dáil Covid-19 committee.
In April, the IHCA invited a number of private consultants to join a negotiating group, which met with Minister for Health Simon Harris. But the meeting proved fruitless.
In May, division emerged once more as private consultants who had agreed to the deal signalled their intention to resign from the contract.
In the end, around half of the 600 private consultants nationally signed the deal. At Bon Secours Hospital, Cork, 97 per cent of the 60 private consultants signed the public-only patient contract.
At the Covid-19 committee, Mr Varley said “the private hospital contract is prohibiting the provision of urgent care required by patients with non-Covid illnesses”.
“This is leading to the accumulation on waiting lists of a large number of patients who require urgent care. There is now the additional risk that these patients will deteriorate clinically and will increasingly evolve into emergency cases if they are not treated without delay.”
The Dáil Covid-19 committee heard how the arrangement delivered 7,600 inpatient treatments, 26,000 day case procedures, 24,000 outpatient appointments, and 35,000 diagnostic tests.
But many surgeries and procedures were postponed in private hospitals and private consultants will now have to manage larger waiting lists than before the deal.
‘Poor value’ for money
The Dáil committee heard the arrangement cost €97 million in April and around €100-to-115 million will be spent in June. The total cost of the deal will be around €350 million.
Was this a waste of taxpayer’s money? The answer is ‘yes’, according to the IHCA and many consultants.
Mr Varley told the committee that the deal “represents poor value for money from patient care and taxpayer perspectives”.
This claim was rejected by Mr Jim Breslin, Secretary General at the Department of Health.
“We were using the resources of the State for the most valuable thing we could possibly do, which was to prevent people needing to access our healthcare services and not having hospitals available to them. I stand over the decisions that were made,” he told the committee.
The view that the deal represented bad value for money stems from the fact that private hospitals were never at full occupancy, or even close to it, under the arrangement.
Data on bed occupancy shows that at the end of April, occupancy in private hospitals was only 28 per cent. At the end of May, it was 37 per cent.
The low bed occupancy levels were a source of huge frustration for private consultants.
Dr Donal O’Hanlon, IHCA President, wrote to Minister Harris on 30 April, warning of low capacity levels in private hospitals.
“Private hospitals are currently operating well below capacity and run a serious risk of being underutilised in the months ahead, if practical solutions in terms of less costly consultant contract options, including type B and C contracts together with contracts for services, are not provided,” he said.
“There is a need to facilitate the utilisation of consultant room facilities more fully to cater for the increased demand for outpatient care that is accumulating during this period.”
He concluded: “There is an urgent and essential need to utilise these capacities and deliver value on the significant costs being incurred by the State on the service-level agreements with private hospitals.”
Private rooms
Separately, consultants who signed-up to the deal were expected to maintain their private rooms, which can cost consultants up to €20,000 a month, without State support.
Some hospitals offered to cover these costs if consultants signed the temporary contract, but consultants have yet to receive any payments, it is understood.
Mr Varley told the committee: “It is only in the last week or two that we have had absolute clarity that a private practice consultant who has signed the contract is also indemnified for treating patients in his or her outpatient clinic”.
“If a less-costly contract had been offered, the cost of rooms would not have been an issue.”
He added: “I am not aware of any private practice consultant who has signed the contract who has had his or her significant rooms’ outpatient costs covered.”
Furthermore, another disincentive for consultants was the fact that the contract was not made available to them until at least four weeks after the PHA deal was announced.
One consultant who spoke to this newspaper said he was not prepared to sit and wait for the contract while his patients remained in need of care.
With his own indemnity in place, he was able to develop a telehealth consultation service for patients and did not sign the contract.
Turning sour
As the weeks went on, more consultants spoke out against the deal. But some became less vocal after verbal and written warnings were issued by hospital management.
The ire among many long-serving private consultants also led to the resignation of IHCA Vice President Dr Durcan.
She resigned from her post at the end of April following an onslaught of “abuse” and “harassment” directed at her by private consultants.
In a letter to IHCA officials on 27 April, seen by the Medical Independent (MI), Dr Durcan said she was not willing to accept “bullying and harassment” as part of her voluntary role with Association.
When outlining her reasons for stepping down, Dr Durcan said her opinion that private consultants — whose issues she believed lay with their individual hospitals — should move on to treating patients was at odds with that of the IHCA and some private practice clinicians.
Relations between the IHCA and private consultants became more acrimonious. So much so that a new association, the Medical and Dental Consultants Association (MDCA), has been formed.
Full-time and part-time medical and dental consultants in private hospitals will be invited to join.
According to Mr Fergal McGoldrick, Orthopaedic Surgeon at the Hermitage Clinic and founding member of the new Association, other unions have failed to represent the interests of private consultants.
“We do not want another long-term agreement that excludes full-time private consultants,” Mr McGoldrick told MI.
He argued that the State’s failure to offer private consultants a type B contract was significant. The Association, he said, would function “as a robust organisation to protect private practice”.
One of the major problems with the deal was the varying impact felt by private consultants, depending on their hospital and area of expertise, he said.
Consultants who declined the contract offer were effectively locked out of their hospitals, unable to undertake procedures and provide continuity of care to patients.
Another element to emerge from the deal was a ban on testing samples for potential cancers at private hospitals if the samples were from consultants who had not signed the temporary type A contract. When highlighted in the media, the policy was immediately withdrawn.
Benefits
The deal was not without its merits, particularly for public patients.
Anecdotal reports from clinicians nationally noted how public patients had gained access to procedures in private hospitals currently not available in the public system.
For instance, there are only two places in Ireland that offer cardiac MRI, both of which are private: The Bon Secours Hospital, Cork, and the Blackrock Clinic. Under the deal, public patients gained access to cardiac MRI.
The arrangement also led to progressive collaborations between public and private consultants. In Cork, private consultants worked with colleagues in public hospitals to develop a programme providing chronic total occlusion procedures at Cork University Hospital. The collaboration is set to continue.
Future
Grave concerns remain around hospital capacity and Covid-19 ahead of what many clinicians believe will be a hugely challenging winter for both patients and staff within healthcare.
Mr Breslin informed the Dáil committee they would be able to secure 100 per cent capacity in private hospitals if a resurgence in cases occurs.
Many consultants would like to see improvements in the public system instead of another takeover of the private hospital system.
All are agreeable to some private capacity being used in the event of a resurgence in cases, but are opposed to a situation that could lock out patients and staff once again.
The situation has not been helped by the fact that Ireland has one of the lowest percentages of consultants per capita in Europe.
Furthermore, there are fewer hospital beds now than in the past, despite our larger population. In addition, waiting lists for care are much longer than in other EU countries.
As Mr Breslin said: “The capacity within the private sector is an important feature of Ireland’s healthcare infrastructure.
“It has a role to play in meeting the challenges we face in continuing to be prepared for any subsequent wave of the disease and for meeting ongoing healthcare needs”.
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