Dr. Peadar Gilligan:

The most commonly held contract is the 2008 type B contract which is held by over half of consultants. If a consultant who currently holds a type B contract held a contract prior to signing the type B contract in 2008, that consultant will have the right to off-site private practice, and may also spend up to 30% of his or her time engaged in private practice in facilities operated by the employer. If the consultant, who now has a type B contract, did not hold a contract prior to 2008, he or she has a right to devote 20% of his or her time to private practice in facilities operated by the employer. It is worth noting too that if an employer cannot provide a type B consultant with facilities on the hospital campus for outpatient private practice “the employer shall make provision for such facilities off-campus, on an interim basis, pending provision of on-campus facilities.” In many cases, such on-site facilities were not forthcoming.

As can be seen, the contractual landscape against which consultants operate is a complicated one. The position of the IMO is clear: contracts must be upheld. The "RTÉ Investigates" programme presented several extreme examples of alleged non-compliance with contractual obligations and suggested that this was representative of the practices of "a significant minority" of consultants. It is worth remembering that there are approximately 3,000 consultants in the system, suggesting that the apparent actions of a very small number of consultants is in anyway representative of the group, as a whole, is simply not tenable. Indeed, we note that both the Minister and the HSE, in responding to the programme, accepted that the overwhelming majority of consultants worked beyond their contractual commitment.

In respect of the mix of public and private patients in hospitals, while consultants have limited determination over who is admitted, we would point out that the Department of Health’s own report on trends in public and private activity in public acute hospitals found that public patients accounted for approximately 83% of hospital discharges over the period 2012 to 2016. The National Treatment Purchase Fund is daily evidence that not only does the Government know that public hospitals are unable to provide timely care, but that it is willing to use public funds to pay the private sector to provide care that should be available in public hospitals, but is not, due to inadequate resourcing of the acute hospital system in Ireland. This under-resourcing, which is the default position of the Government, results in ward bed closures, closed operating theatres, cancelled planned admissions and delayed emergency admissions, with the resultant patient hardship and staff being frustrated in their efforts to deliver timely optimal care.

Hospital management has, within the 2008 consultant contract, the ability to first notify a consultant if his or her private practice ratios are in breach of the public-private ratios set out in their contract, and to advise that these ratios must be met within six or nine months. However, hospital management is in the invidious position of simultaneously having to advise consultants if they exceed their allowed private public ratio, while at the same time needing to maximise funding for the hospital received from private patients and their insurers. Each year, the HSE sets each hospital a target for private practice income to be generated. The HSE’s very own service plan for 2016 requires that acute hospitals' private income receipts vary from the planned target by no more than 5%. Approval was given by the HSE, and the Minister, to promote the generation and collection of private charges income.

Let us be clear, the inconvenient truth is that private practice in public hospitals helps to pay for the delivery of care to public patients. Yet again due to the lack of capacity in the acute hospital system it is not uncommon for a public patient to be in a designated private bed due to clinical need which has income loss implications for the public hospital and in turn implications for funding of care in the hospital. In excess of 44% of the population of Ireland hold private health insurance and as such can opt to be treated as a private patient in hospital. Consultants cannot deny a patient an emergency admission to hospital because he or she holds private insurance and so the consultant's ability to control his or her public-private mix is challenged by the number of patients he or she admits on call as emergencies who elect to use private health insurance for that admission. Typically consultants are unaware, and rightly so, that a patient under their care as an emergency admission is a private patient until such time as he or she is made aware of this by hospital management in order that the hospital can then bill the patient’s insurer for his or her hospital stay and generate much needed funds.

At present, we in the public health service are experiencing a recruitment crisis when it comes to consultants. We simply do not have enough consultants and are struggling to recruit new highly trained colleagues into consultant posts. The National Task Force on Medical Staffing from 2003 suggested that we would need 4,400 consultants to deliver specialist medical care today. However, we have just over 3,000 approved consultant posts, of which 200 are filled on a temporary basis only, and an indeterminate number, approximately 400, are either vacant or otherwise filled on an unclear basis. We are not recruiting consultants in sufficient numbers to deliver a specialist medical service or to meet required replacement rates. In 2016, eight advertised consultant posts received no applicants; a further 22 posts received just one applicant and 21 posts received just two applicants. Overall, 66 advertised posts received five or fewer applicants.

Most damningly, perhaps, figures produced by the Public Appointments Service, which runs recruitment campaigns on behalf of the HSE, show it was “unable to identify a suitable candidate” for 22 of the 84 posts that were advertised in 2016. If we propose to have a health service delivered by suitably qualified medical specialists this cannot be allowed to continue. Using financial emergency measures in the public interest, FEMPI, legislation and other devices health service management has driven down the pay of consultants. We are not competitive internationally and the recruitment figures would suggest we have given up even trying to compete.

With all due respect to the makers of the programme, to focus on the alleged actions of a tiny number of unidentified doctors is to miss the much larger point.