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The coming weeks will be an important period for politics and healthcare in Ireland. The run-up to Budget 2018 is seeing sharp discussions over spending, the hotly-debated Public Health (Alcohol) Bill may be passed by the end of autumn, and the Government is due to set out in detail how it plans to implement the all-party 10-year vision for healthcare, Sláintecare.
Thus IHCA delegates will have much to discuss with Minister for Health Simon Harris when he addresses the IHCA Annual Conference this Saturday morning, 7 October, in the Strand Hotel, Limerick.
These themes do not even include the ‘usual suspects’ — those topics that have continually challenged consultants in recent years, such as the recruitment and retention crisis, the pressing need for infrastructural spending in acute hospitals, and the rising cost of clinical indemnity.
If his recent speeches are to be taken as a guide, Minister Harris can be expected to speak about Sláintecare, the final report of the Oireachtas Committee on the Future of Healthcare published in late May. The Minister has already said that implementing the report is one of his top priorities and he is currently working on a full-Government response to the decade-long framework for the health service. It is clear that if the report is implemented in full, it would have a significant impact on the working lives of all those in the health service, including hospital consultants.
For its part, the IHCA’s response to Sláintecare has been sceptical at best.
In May, in an early reaction to the report, the Association claimed it “does not contain realistic solutions to address the overwhelming shortage of hospital beds and other facilities, which are causing unacceptable waiting lists and delays for patients in public hospitals”.
At the time, IHCA President Dr Tom Ryan described the report’s proposal to remove private care in public hospitals as a particularly bad idea, likely to give rise to a “more extreme two-tiered acute hospital system due to inadequate public hospital capacity”. Dr Ryan also cautioned that the report would not help alleviate what the IHCA sees as a “recruitment and retention crisis” among consultants.
Two months later, and IHCA leadership still sounded somewhat uneasy about the report.
This summer, at the Association’s pre-Budget 2018 submission launch, the Medical Independent (MI) asked leading members of the IHCA whether they were concerned that all the talk of the ‘shift to primary care’ in the Sláintecare report might mean less focus on acute and hospital issues.
“I have two main comments on it,” Dr Ryan responded to MI’s question in late July.
“First of all, there are 80,000 people waiting for elective surgery; they have to be accommodated in a hospital. There are people on trolleys in hospitals [and] they have to be accommodated,” he said.
“There are 400,000 people waiting to see a consultant in a hospital; they have to be accommodated. We all recognise that we are short of diagnostic facilities, CTs, MRIs, endoscopies, etc.
“We recognise that we have fewer hospital beds than most other OECD countries and we have shown you data that there are [delays] for elective surgery for hip and knee replacements, and that is just a concrete example of it, that we are way below our OECD comparators.”
Dr Ryan added that in other OECD countries where investment in primary care is high, there is also high investment in acute services.
“There is coherent, cogent data to show that the public hospital system is short of money, short of facilities, short of infrastructure. So there has to be investment in the public hospital system,” said Dr Ryan.
“We know that in countries with a more developed primary healthcare system, such as France and Germany, they have 50-to-100 per cent more hospital beds. So they have invested in public and community care, they haven’t closed hospital beds; they have doubled them.”
Dr Ryan did acknowledge that “yes, community care is great. If you get everyone to take more exercise, lose loads of weight, stop drinking and smoking, there would be an obvious healthcare benefit in one or two decades”.
But he warned that “we need something for the trolleys and the waiting lists of today”.
Hospitals vs community?
Similarly, in response to MI’s question about Sláintecare, IHCA Secretary General Mr Martin Varley said: “We all accept there is a need for increased funding for community care”.
However, he added: “Can more be done in primary care? Of course it can. Can it do everything? No.
“The patients who are presenting in emergency departments who are admitted for inpatient care on trolleys are admitted patients who need acute care in the hospital. The patients who are on a [surgical] waiting list, the 85,000, 90,000 or so, they are all waiting for appointments for hospital care. So there is a huge problem in terms of under-funding in acute hospitals.”
The IHCA Secretary General did make clear that he did not see this as a situation where primary care and hospital care needed to be in competition.
“We are not for one moment saying that there isn’t the need for extra funding in community and primary care,” said Mr Varley.
“However, I think it is incorrect to suggest that you can resolve the problem by just funding the community and primary care, because it is very obvious that people are on waiting lists for hospital care.”
In terms of what the IHCA members see as the “escalating cost of clinical indemnity”, the Association is seeking that the “relevant provisions of the Legal Services Regulation Act 2015 must be commenced without further delay, so that the Pre-Action Protocols are implemented to resolve clinical indemnity claims more efficiently and at reduced cost”.
This is something that the leaders of the Association are expected to raise with the Minister in their meeting on Saturday, and which the Minister addresses in his article for MI (see page 17).
In its pre-Budget 2018 submission, the IHCA warned that the rise in indemnity costs was “forcing consultants to cease practice or emigrate”. The issue will be addressed in the scientific session on the Saturday afternoon of this weekend’s meeting, as Ms Emma Hallinan, Director of Claims, MPS, will address delegates on ‘Pre-Action Protocols and Clinical Indemnity Issues’.
Speaking alongside the Minister in Limerick this Saturday morning will be Dr Ryan (Consultant in Anaesthesia and Intensive Care, St James’s Hospital, Dublin) and also Prof Ken Mealy, Consultant Surgeon and RCSI President Elect.
The questions and answers session will likely heavily feature the recruitment and retention crisis. The Association has consistently maintained that the FEMPI salary cuts imposed on consultants since 2009 must be reversed. In addition, the IHCA has long argued that the terms of the 2008 Consultant Contract must be honoured in full and what it regards as “the discrimination” against new-entrant consultants must be brought to an end.
At the end of July 2017, there were 2,892 whole-time equivalent consultants employed by the HSE, an increase of 105 on the corresponding month in 2016, and a rise of 700 consultants in the past decade. However, many of these posts are locum posts, and there are currently around 400 posts vacant. Eight or nine years ago there was, on average, at least six applicants for every consultant post advertised. This is now down to under two applicants per consultant post advertised, Fine Gael Senator Colm Burke pointed out this summer.
In recent months the IHCA has also raised concerns over the number of consultant posts within public hospitals being filled by non-specialist doctors, something it sees as a result of the ongoing staffing crisis.
In its recent pre-Budget 2018 submission, the Association said it was “unacceptable that over 400 approved hospital consultant posts are either vacant or filled on a temporary/agency basis”. The Association called it a “false economy”.
The IHCA believes the fact that “70 non-specialist doctors have been appointed to specialist consultant posts since 2008 demonstrates the extent of the failure of current health service policies to address the ongoing exodus of highly-trained consultants”.
Speaking in August, Mr Varley said “as a result, there is a growing risk that temporary appointees, who do not have the required specialist training and qualifications, will become entitled to permanent consultant posts once they become eligible for ‘contracts of indefinite duration’ after four years in-post”.
The Medical Council has also recently raised concerns about the issue. In an interview last month with this paper, Medical Council CEO Mr Bill Prasifka said the Council has noticed this trend, however it is a challenge to be faced primarily by employers within the health service.
“We have to operate under the Medical Practitioners Act and the issue here is the appointment of consultants who are not on the specialist register. The simple fact is that under the Act, ‘consultant’ is not a defined term,” said Mr Prasifka.
“A ‘consultant’ is effectively an internal HR term used by the employer. The only legal requirement in Ireland is that, number one, if you practise medicine you must be on the register, and number two, if you hold yourself out as a specialist you must be on the specialist register.
“Let’s put it this way, we are concerned with consultants being hired who are not on the specialist register. Such a practice is in fact contrary to the HSE’s own guidelines. But there is very a limited role for the Medical Council here because the term ‘consultant’ is not a defined term.”
Writing in this edition of MI, Minister Harris insists that there are some positive signs in terms of consultant recruitment. “The number of consultants employed in the public health system continues to increase,” writes Minister Harris, pointing to the latest figures.
“However, we remain some way from having a consultant delivered service,” the Minister admits.
But there is not merely the impact on salaries or consultants deciding whether to work in Ireland or not. The IHCA see the current crisis as having a serious negative impact on important public health policy initiatives, such as the Government’s National Cancer Strategy 2017-2026.
On it publication in July, the IHCA welcomed the new document; “the Strategy’s focus on cancer prevention, increased awareness and screening with earlier diagnosis and treatment are critically important,” said Dr Ryan.
However, the IHCA President also delivered a stark warning that “widespread shortages of acute hospital beds, operating theatres, intensive care beds and diagnostic facilities” would have to be dealt with if the Strategy was “to fully succeed”.
“There is also a parallel need to recruit and retain key medical and ancillary staff in the public health system to realise the benefit of this much-needed investment in patient care,” said Dr Ryan. He added that at consultant level, this has a significant relevance, given the need to recruit and retain specialists in medical and radiation oncology, haematology, dermatology, radiology, pathology, urology, gastroenterology, genetics, surgery, palliative care and psycho-oncology.
He also stressed that the other significant threat to the delivery of improved cancer care and acute hospital services “is the overwhelming shortages” of acute hospital and ICU beds, theatre operating time and access to modern diagnostic facilities.
In its recent submission to the HSE’s ongoing bed capacity review, being carried out by PA Consulting, the Association warned about capacity challenges.
The IHCA submission calls on the Government to “at a minimum” increase the number of additional acute hospital beds by 4,000, ICU beds by 290 and rehabilitation beds by 500.
The Association also wants “increased capital investment across the entire hospital infrastructure for the maintenance and replacement of essential equipment” and “an increase in nursing home and long-term care capacity to reduce the number of beds occupied by clinically-discharged patients”.
The submission also notes that thousands of elective surgical procedures are having to be cancelled every year due to bed shortages and emergency department overcrowding, further exacerbating record public hospital waiting lists.
In his article for MI, Minister Harris admits that capacity challenges are “being experienced right across the health system”. The Minister said he is “taking steps to address” the issue, citing the bed capacity review, beginning work on a number of major capital projects and “further expanding care in the community and intensifying recruitment and retention efforts”.
However, that will be of little comfort to hospital consultants facing another winter of extreme pressure in the acute system.
As IHCA delegates gather for the Association’s biggest meeting of the year, the stark situation of the health service will dominate proceedings.