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The health service in Ireland is no longer internationally competitive in attracting the number of highly trained specialists needed to treat a growing number of patients and to develop the services required. This is due to the State’s blatant and repeated breach of contract terms and discrimination against new entrant consultants. Combined with frontline under-resourcing, these fundamental breaches of trust continue to undermine the attractiveness of the Irish health service to highly trained internationally mobile specialists.
In 2015, one-in-four advertised consultant posts received no applicants and a similar number received only one applicant per post. The filling of hundreds of vacant permanent consultant posts requires the restoration of trust through the State and employers, ending the discrimination against new entrant consultants, honouring the 2008 Consultant Contract, reversing salary cuts imposed in 2010 and 2013, and other actions to improve Ireland’s international competitiveness in recruiting and retaining consultants.
If the State and health service management do not honour the 2008 consultant contract terms entered into with consultants, these matters will be determined in the courts. In December 2015, the Employment Appeals Tribunal issued a positive determination in cases taken by two IHCA members, awarding them the salary underpayments plus compensation. These cases have been appealed by the HSE to the High Court with hearings scheduled in January 2017. In addition, hundreds of IHCA members have issued proceedings against their employers for breach of contract and it is expected that the first of these will come before the courts in the near future.
Critical capacity constraints
International and other comparisons confirm that Ireland’s health service has one of the lowest number of practising doctors, a relatively low number of acute hospital beds, and significant theatre, ICU, and other critical capacity deficits.
These constraints are resulting in unacceptable numbers on waiting lists, a growing number of patients being treated on trolleys, cancellation of surgical appointments, and an excessively high bed occupancy rate. In addition, far too many clinically discharged patients are needlessly occupying acute beds due to a failure to provide step-down, home care, and other supports. There are also problems with outdated, malfunctioning, and obsolete equipment. These constraints and problems have deteriorated over the last decade, further undermining the delivery of care to patients.
Cumulative cuts in annual health capital budgets in the last eight years totalled €1.7 billion, including a €530 million cut imposed on the acute hospitals. Consequently, the acute hospital infrastructure is now crumbling, with many hospitals attempting to treat patients with inadequate facilities and equipment that is increasingly obsolete.
The effectiveness of our acute hospital services depends on immediate increases in the number of acute, ICU, and rehabilitation beds, in addition to increases in operating theatre, diagnostic imaging, and outpatient clinic capacities.
Future resourcing and 10 year strategy
The future resourcing of acute hospitals and mental health services must take full account of existing unfunded and unmet patient care needs, together with future demographic and other pressures, which will increase the demand for care further. This requires realistic and verifiable projections, which take account of the increased number of patients awaiting care, the rising prevalence of chronic disease, an ageing population, and other demographic pressures.
The 10 year strategy, which is being developed by the Oireachtas Committee on the Future of Healthcare, must provide a blueprint outlining the increased capacities which will be put in place each year in acute hospitals, mental health, and other services, to ensure that care can be provided to the growing number of patients presenting for care.
Waiting list targets for inpatient and day-case procedures include reference to an outer limit of 18 months, which is unacceptable and represents an excessive delay for patients. The health service must be resourced to provide care with minimum delays in order to reduce the number of patients on waiting lists. Furthermore, hospitals must have sufficient capacity and flexibility to adapt to, and cope with, fluctuating demand at different stages of the year based on seasonality and other factors.
Unsustainable clinical indemnity costs
Current clinical indemnity costs are unsustainable. They are driving up the cost of providing care in public and private hospitals. In addition, they are jeopardising private practice in surgical and other specialties and forcing consultants to cease practice and emigrate. The cost of clinical indemnity more than doubled for most specialties in the two year period commencing 2013 and in addition further steep increases were imposed on some specialties and sub-specialties in 2015 and 2016.
There is a pressing need for the State to urgently implement regulations and rules of court to give effect to the newly enacted legislation on pre-action protocols. This is essential to ensure that cases are dealt with more quickly and within defined time periods, with significant penalties where these are exceeded, to reduce delays and costs. There is also an urgent need for the Cabinet to reduce the indemnity caps as recommended in the Oireachtas Health Committee report in June 2015.
The existing governance arrangements in public hospitals and mental health services have undermined the trust of patients, consultants, and other healthcare staff. Clinical governance in the majority of hospitals and CHOs is constrained, due to the limitations being placed on the authority of clinical directors and executive clinical directors. Combined with the failure to facilitate the required clinical governance input at organisational board levels, this is undermining the prioritisation of issues that need to be addressed on an ongoing basis to deliver safe, high-quality care to patients on a timely and consistent basis. It is essential that the current focus of governance is re-balanced to facilitate increased clinical governance input at organisational board levels to ensure the appropriate prioritisation. In addition, Hospital Group and CHO geographical coverage must be aligned without delay.
In conclusion, frontline acute services need to be urgently resourced to address inadequate capacity and to enable consultants to provide care to patients without the existing unacceptable delays. In this respect, it is critically important that the 2017 health budget and the 10 year strategy address the root causes of the capacity constraints and frontline staffing shortages.