Dr. Tom Ryan:

The Irish Hospital Consultants Association, IHCA, welcomes the opportunity to attend the committee's discussion on the recent "RTÉ Investigates" programme. With regard to contractual obligations, the IHCA wishes to be absolutely clear that its consistent stance is that consultants must abide by the conditions of their employment as outlined in the various consultant contracts. If consultants who do not fulfil their contractual hours, it must be clearly understood that any such consultants are not representative of the profession.

The agreed administrative procedures for dealing with such matters are clearly provided for in various consultant contracts. The Irish Hospital Consultants Association, IHCA, is of the view that such matters should and must be addressed through the contract mechanism by hospital management.

In reality, the vast majority of consultants work well in excess of their contracted hours and this has been confirmed over the days since the programme was aired by the Minister for Health, Deputy Simon Harris, and by Mr. Liam Woods, HSE national director of acute hospitals. As a consequence of our commitment, in the past decade the IHCA and its members, in collaboration with health service management, have delivered significantly increased productivity in the acute hospital system at a time of extraordinary cuts to health sector funding. It is worth considering that while acute hospital budgets were cut steeply compared with 2008, the total number of inpatient and day-case patients treated has increased by approximately 275,000, or by 22%. In other words, consultants have been instrumental in dramatically increasing productivity in the health sector. Over this same decade, when our population expanded by 12%, and the cohort aged 65 years and over increased by one third, the number of inpatient acute public hospital beds was reduced by more than 1,400. The result is that our hospitals are almost continuously full with patients. OECD data confirms that they operate at 95% occupancy, which is way above the OECD average of 77%. The OECD average is recommended so as to prioritise consistent safe patient care and to guard against resistant and cross-infections.

As a direct result of the lack of hospital beds, the average hospital stay in Ireland, at 6.2 days, is much shorter than the OECD average of 8.2 days. Ireland hospitalises far fewer patients - 139 per 1,000 - on an annual basis than the average OECD country of 169 people per 1,000 of population. That is because of the overwhelming shortage of beds in Ireland. Department of Health data confirms that hospital consultants make up less than 2.5% of the overall public health service work force, which contrasts with 4% in the National Health Service in the United Kingdom. In Scotland, which is equivalent to our size and which has a population that is just 13% greater than Ireland’s, there are more than 5,000 hospital consultants, compared with approximately 2,600 permanent consultants in post in Ireland. There are significantly fewer hospital consultants in Ireland on a comparable population basis.

The association is emphatic that the paucity of hospital beds and the shortages of hospital consultants are the fundamental causes of waiting lists for patients in Ireland. Department of Health data confirm that currently 80% of acute hospital admissions are emergencies and the volume of elective surgery performed in acute public hospitals has progressively declined over the past decade. Accordingly, hospital admission in Ireland is increasingly only feasible for patients with emergency medical and surgical conditions due to the shortage of beds in our system. This is exacerbated year-on-year because of demographic trends with our ageing society. Against the backdrop of an under-resourced and understaffed public health system, the association continues to recommend to its members that they report to their relevant clinical director so that they can work in teams with their clinical colleagues to an agreed practice plan. This is important to provide the best possible patient care during daytime hours and as part of organised on-call services at weekends. The IHCA is strongly of the opinion that the vast majority of consultants work in accordance with an agreed practice plan and are more than fulfilling their contractual hours.

The 2008 contract delegated certain clinical governance roles in the acute hospitals and mental health services to clinical directors. Frequently, however, clinical directors encounter significant difficulty in fulfilling their role, as they have not been provided with the necessary support staff and infrastructure. It should be clearly understood that consultants who do not fulfil their contractual hours are not representative of the profession. There are agreed administrative procedures for dealing with such matters, which are clearly outlined in the contract. The IHCA is available to engage with hospital management, as necessary, on such matters. With regard to the ratio of public and private patients in public hospitals, it was agreed in the 2008 contract that the ratio should not exceed 80:20, with a provision allowing some consultants a 70:30 ratio. These ratio provisions were incorporated in the 2008 contract, with a clear reference to the Government policy of that time in 2008 that co-located private hospitals would be built on public hospital sites. The Government policy committed to putting in place an additional 1,000 such co-located private hospital beds, and furthermore the 2008 contract explicitly permits hospital consultants to treat patients in co-located hospitals. However, in 2011 the co-location policy was abandoned by the then Government, and as a result the additional 1,000 acute hospital beds in co-located private hospitals have not been commissioned. The concomitant closure of a further 1,400 inpatient beds in our acute hospitals has clearly driven the waiting lists to their current levels.

Crucially, it is widely acknowledged that the methods used to measure public to private ratios are both inaccurate and unreliable. This was identified as a problem in an independent management report commissioned by the HSE in 2007 during the contract negotiations. In 2011, the IHCA and senior HSE management agreed that those serious flaws in the systems and methodology needed to be rectified, but that has not happened as yet. The annual revenue from private patients in public hospitals amounts to more than €600 million, or some 15% of the public acute hospital funding. This may be higher in some hospitals. The revenue private patients bring to the public hospital is an essential source of funding. One should bear in mind that without this revenue our public hospitals would collapse. Public acute hospitals could not deliver the current level of service to the public without this revenue, let alone hope to expand or improve the clinical service that we aspire to deliver to patients.

Health service management and consultants were blamed in a recent RTÉ programme when the proportion of private patients admitted to public hospitals apparently exceeded 20%. We know from Department of Health data that over 80% of patients admitted to acute hospitals are emergencies. Given that more than 45% of the population holds private insurance, and more than 50% of patients in the over 40 age group hold such insurance, the proportion of private patients attending a public hospital may exceed 20% as a routine. Under these circumstances, blaming hospitals and consultants whenever the ratio of private patients exceeds 20% is not a reasonable stance to adopt. In effect, such hospitals are blamed for providing care to the cohort of patients who present for care, and which reflects the demographic composition and insurance status of the patients in their catchment area. Neither consultants nor hospital management has any control over such matters.

The demand for patient care is increasing due to demographic factors. A recent ESRI study projected a 37% increase in the need for inpatient and day-case capacity by 2030. In real terms, this means our current 10,000 bed capacity must be increased to approximately 14,000 beds. In contrast, there are growing public hospital capacity deficits due to the cumulative lack of investment in hospital infrastructure and equipment over the past decade. This is the root cause of the unacceptable waiting lists in Irish health care. It is a distraction from the reality of the effects of long-standing underfunding to blame hospitals and their consultants for current waiting lists when they are, in effect, being prevented from providing care. With regard to elective waiting lists, patients should be treated exclusively based on clinical need. Waiting lists are the norm in the hospital where I work and in the vast majority of other public hospitals.

I thank the committee for the invitation to attend this session.