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Consultant work practices coming under sharp focus

It’s the consultants, stupid.

This suggestion has featured prominently in the debate about the causes of hospital overcrowding.

The argument that consultants are significantly contributing to the crisis by not being sufficiently present on weekends and evenings, thereby restricting patient discharge, has been utilised by Minister for Health Simon Harris, a range of journalists and media commentators, and the Irish Nurses and Midwives Organisation (INMO).  The previous minister, Leo Varadkar, also critically highlighted consultant work practices while in post.

Last October, Dr Michael Harty, an Independent TD and GP, referred to a lack of senior decision-makers “on the floor seven days a week” in hospitals. Speaking at the Conference of Rural, Island and Dispensing Doctors, he said some consultants were very powerful in their hospitals.

Speaking to the Medical Independent (MI), Dr Harty, who is a member of the Oireachtas Committee on the Future of Healthcare, said changing work practices in hospitals would demand extra consultants.

He added that in many cases, patients are referred to EDs by their GPs, with a diagnosis, only to be ‘second guessed’ by junior decision-makers.

‘Disgusted’

The phrase ‘senior decision-makers’ is now in common usage, and technically can mean professionals beyond consultants, yet is usually contextualised by reference to specialist doctors.

But many consultants have been strongly challenging this narrative on social media. 

Among them is Dr Anthony O’Connor, a Consultant Gastroenterologist at Tallaght Hospital, Dublin. He told MI he has been “pretty much disgusted with the way the media have made this [overcrowding crisis] about consultant work practices”.

He invited any media commentator who thinks the situation has “anything at all” to do with consultant work practices to come to his house to speak to his family.

“They could explain to [the kids] why their daddy needs to spend even more time at work. How it seems the entire cluster-f**k that is the health service problems could be sorted out if their lazy daddy worked seven days every week, rather than just every third week.”

Perhaps his wife could tell them about “what it’s like to live with someone who works 70-hour weeks routinely, when the phone can never be switched off, when your husband lies awake at night thinking of his responsibilities”, suggested Dr O’Connor.

Prof Louise Kenny, a Consultant Obstetrician and Gynaecologist at Cork University Maternity Hospital, noted that her specialty has just 3.95 consultants per 1,000 deliveries.

“This is about half the number of consultants in the UK for the same number for births, yet our clinical outcomes are comparable. This is indicative of the significant work by all my colleagues who work long hours, at night and at the weekend, to provide safe maternity hospitals.”

Speaking on her working environment — maternity and paediatric services — she said it was “simply not true” that consultants were not present after hours.

“We provide clinical care and make life and death decisions 24/7, 365 days a year. For example, I have worked nine out of the last 10 Christmases — either Christmas Eve or Christmas Day.”

Prof Kenny also referred to factors inhibiting retention of trainees and consultants, including the “highly divisive and completely inequitable” 2012 consultant contract.

She added that having worked and trained as a consultant in the UK, and travelled extensively as Director of the Irish Centre for Fetal and Neonatal Translational Research, she believes Irish consultants “work far harder and longer than any of our international peers”.

President of the IHCA Dr Tom Ryan, a Consultant in Intensive Care and Anaesthesia at St James’s Hospital, Dublin, underlined that the main constraint on delivery of timely care is the lack of capacity in acute hospitals, especially during surges in demand.

He said many specialties have one-third to a half of the international recommended norms for consultant staffing.

“In addition, currently 370, or 15 per cent, of the permanent acute hospital consultant posts are either vacant or filled on a limited basis, either through temporary or agency consultants. In these circumstances, in addition to working a full week, hospital consultants provide 24/7 acute services to patients through their on-call availability on weekends, evenings and at night. These acute services also include the presence of senior doctors, who provide 24/7 on-site care to patients as part of acute medical/surgical teams, in conjunction with the on-call consultants.”

He described a “serious shortage” of diagnostic facilities and consultant radiologists.

“It is not possible to extend the consultant radiologist reporting into weekends and out-of-hours without it adversely impacting on the availability of radiology reporting during the normal working week,” Dr Ryan told MI.

Union tensions

A touch of seasonal frost has also now enveloped the usually cordial public relations between the IMO and INMO following statements around doctor work practices.

On RTÉ News in early January, the INMO’s General Secretary Mr Liam Doran made reference to patient discharge being hampered due to consultants not being present at weekends. He said: “We have to recalibrate how we all work. Nurses are working 24/7; everybody else has to work 24/7 as well.”

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Mr Liam Doran, INMO

Tensions were further stoked on 13 January when the INMO published, via its Twitter account, an image depicting doctors as lazy. The image, it seems, was mainly intended as a critique of healthcare managers. Doctors and nurses on social media were outraged and the union apologised.

Dr Peadar Gilligan, Chair of the IMO Consultant Committee, disputes that consultants have a case to answer.

“I was surprised to hear Liam Doran essentially give out about consultants with regard to the overcrowding crisis,” he told MI last week.

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Dr Peadar Gilligan, IMO

“And I think it was an effort on his part to deflect attention from the fact that he was Co-Chair of the Taskforce related to addressing emergency department overcrowding, which has not really been terribly successful… ”

Dr Gilligan said he had also “essentially used” the Taskforce to further ED nurse IR issues such as promotional posts and annual leave.

He added: “And in fact, one of the few initiatives that makes a difference — that is, enacting the full capacity protocol — his organisation has stood against for a prolonged period of time.”

Is it possible to roster 24/7 due to the oft-cited shortage of consultants?

“It is possible and every hospital in the country will have consultants who are both doing their working day and are actually on-call thereafter,” said Dr Gilligan.

“The reality of that, I think, is lost on an awful lot of people, but that means essentially that they work a full day, they then go home at whatever time they do go home in the evening, but there is quite a considerable chance they will be called back in to work again, despite having worked a 10-hour day or even longer in many cases. And they would have been doing that over the holiday period.”

Resources

Many consultants are frustrated at not having the required resources and surgeons are one group that comes to mind, said Dr Gilligan. Surgeons “frequently contact” the IMO to say their operating lists have been cancelled and patients are suffering.

Surgeons, however, are among those doctors most active in private practice alongside public commitments. Some observers have suggested that public cancellations are, in one sense, not so bad for surgical consultants. The argument goes that surgeons and others in public/private practice can seek out extra slots at private hospitals while picking up their public salary. Could surgeons be more vocal on overcrowding?

“I think an awful lot of them are really frustrated about it, and do talk about it to their colleagues,” responded Dr Gilligan. There is also an issue of maintaining skill-set when public lists are postponed or cancelled, he said. 

Asked if there were any practices that consultants needed to develop, such as cross-consultant discharge, Dr Gilligan maintained this was happening.

“Most consultants now work in multi-consultant teams and will in advance of, for example weekends or that sort of thing, have a list of patients that can potentially be discharged if, for example, their x-ray has normalised or their blood tests are improving, or they have had the occupational therapy or physiotherapy or social work input that is required. Oftentimes, they will share that with the on-call team to let them know that, if these things happen, then that patient could go at the weekend — so that is happening.”

Dr Gilligan noted that the commentary against consultants, which he said the HSE was also engaged in “doesn’t help” recruitment and retention, “which is a major challenge at the moment because of the breaches in contract that have happened over the last number of years”.

‘Rubbish’

Mr Doran at the INMO describes as “rubbish” the accusation that his remarks on consultant work practices are part of deflecting from his key position on a failing Taskforce. He agreed that this vehicle had not addressed the crisis.

“Not enough money is being committed, not enough expansion of acute bed capacity has happened, not enough expansion of the community services over seven days — absolutely agree with him,” he told MI.

Mr Doran said that if Dr Gilligan “cares to look back”, the INMO has been talking “for years” about “nurse-led discharge, cross-consultant discharge, extended hours of senior attendants, second ward rounds… ”

He added: “If he differs from me in what we are saying, I fully respect that, but if he thinks I am saying it to deflect from the Co-Chairing of the ED Taskforce, then I have to say, he is absolutely and utterly wrong.”

Mr Doran was especially angered by Dr Gilligan’s contention that he had used the Taskforce to further causes such as nurse promotion  and annual leave.

“Number one, we didn’t increase annual leave, but I don’t have to explain myself… the changes that were made in the ED were nothing to do with a Taskforce… they came about because of a dispute in ED, and a WRC agreement of last December and January [2015/16]. Nothing to do with the ED Taskforce at all.”

He said he would strongly advise Dr Gilligan to “check the record” in this regard. 

Mr Doran told MI that the ultimate solutions in addressing overcrowding are more beds, staff and community services. It is a position which is broadly akin to that of the IMO.

“But in the short term, a required initiative is that consultants would be more actively present in emergency departments and in the houses — in the inpatient wards — over an extended day,” maintained Mr Doran. 

He said decision-making often slows down in the evenings, when there is “undue reliance on junior doctors”.

“Senior clinical decision-makers in the evening and at weekends, cross-consultant discharge at weekends, nurse-led discharge at weekends — they are all things that everybody signed up to under the ED Taskforce but I think in some houses, they haven’t happened as well as they can and as well as they have in other houses,” said Mr Doran.

“What roster changes have been made to address the reality of the ED situation? We are not aware, in some houses, of any roster changes.”

MI requested from the HSE any analyses of consultant working patterns, as well as statistics on vacancies. At deadline, despite the query having been sent several days previously, the HSE advised that this information was best sourced from hospitals.

By press time, no responses had been received from the six Hospital Groups.

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