Chair of the IMO consultant committee Prof Matthew Sadlier argues the consultant workforce needs to be rapidly expanded to meet the needs of the population.
“What we gonna do, when the money runs out, I wish that there was something left to say, Where we going to find the eyes to see, the bright of day”.
Night Blindness, David Gray.
Not being David Gray’s accountant I cannot for sure comment if he ever did really see the money “run out”. However, as this song was an integral part of the seven million-selling White Ladder I feel the concern about impending impecunity was all a storm in a teacup. I am writing this as the dark clouds of a possible reordering of the geopolitical financial world are swirling above Merrion Square, one can only hope that the Government’s coffers are as fortunate.
In the world of the consultant committee, the last 12 months have been similar to the 12 months that preceded it. As the year progressed, the number of consultants moving over to the public-only consultant contract (POCC), or ‘Pock’, as seems to have become the accepted vernacular has increased and now stands somewhere around 65 per cent. The winter came with its usual uptick in viral illnesses and with it the surprise and shock at the expected and predicted overcrowding in emergency departments and high trolley counts.
If it wasn’t tragic the annual cycle of winter crisis and stopgap measure after stopgap measure would be almost comical at this stage. Almost every year we have a new HSE Winter Plan with attempts to mitigate the problem. Each year there is a different scapegoat created whether it was private practice in public hospitals, delayed discharges or the more recent one of consultants not being rostered routinely at weekends. However, despite this, the giant-sized elephant in the room is ignored and passed over.
Hanly report
I first got involved in medical politics around 2003 – the time of the publication of the Hanly report. This was an attempt to rationally plan out acute hospital needs to accommodate what then appeared to be the imminent European Working Time Directive. As the Irish acute hospital network had evolved into a mixture of religious/charitable hospitals, repurposed sanitoria and local government controlled ‘regional’ hospitals, there was a need for some overarching plan.
While not perfect, the Hanly report was an attempt to put some sort of structure on the health needs of the population and give a roadmap to where hospital resources needed to be. Unfortunately, to implement the plan required difficult political decisions and, in the face of protest, the plan drifted into obscurity. NCHDs continue to work illegal hours to this day.
In its place we got the vague, mystical and almost meaningless document that was the Slaáintecare Report. This is now held up as some sort of article of faith and even the invocation of the word can be used to justify almost any project. It would be unfair and negligent to say that, despite this, there hasn’t been some excellent community-based services delivered. However, as trolley counts and waiting times will attest, community-based treatment is an adjunct, not a replacement, for acute hospital care.
Capacity
The elephant in the room is the cold hard fact that our acute hospital system has too few beds. The recent history of our acute hospital bed number has been fluctuant to say the least. If we start in 1980 (population: 3.4 million), we had 17,000 beds which by 2000 (population: 3.8 million) had decreased to about 12,000. Bizarrely, there was a period in the late noughties following the publication of the PA Consulting report which suggested that we needed fewer than 9,000 acute beds as enhanced community care would reduce the need for hospital admissions. Currently, with our population sitting at 5.4 million, we have about 12,000 beds. However, the government last year promised an extra 3,438 beds between now and 2031. We need 5,000 additional beds.
Rostering
All this planning and announcements was interrupted by a General Election in November, which returned a new, albeit similar, Government. As our former Minister became a high-profile casualty to the vicissitudes of electoral politics, a new Minister for Health was installed and the conversation moved very quickly to the issue of consultant rostering, especially on weekends.
As an organisation, we are not against consultants working rostered hours over weekends. I will also state that as an organisation we fundamentally believe that nobody’s health outcome should be determined by what day they happen to get sick and turn up to an emergency department. However, I am not sure if what the Minister is asking for will give the answer she wants.
Currently, most consultants work a five-day pattern with on-call services providing care outside these times. Most routine care happens during this period and this working pattern allows consultants to have continuity of care with their inpatients and scheduled outpatients. Unscheduled or urgent care is managed by the on-call system where consultants are available for contact and attend to the hospital depending on clinical need. The intensity and need for on-site attendance varies massively depending on specialty and location. Some consultants (mainly in specialties which don’t deal with chronic disease) have moved to extended days as continuity of care is less important. It should be noted that this system evolved to allow continuity of patient care not because of consultant convenience.
To move to a system where consultants are routinely rostered to come in at weekends would fundamentally change how most hospital specialties operated. Firstly, in order to remain within legal and contractual working hours, the consultant rostered during the weekend would not be present during the week. Given that every patient needs a named consultant, this would mean some system of cover or rostering of inpatient duties for that consultant’s own patients to be developed. This would disrupt the valued continuity of care, meaning additional time spent in handovers where senior staff get to know the new cohort of patients under their care. It would mean a period of reduced discharges around this time, as realistically, a consultant is less likely to discharge a patient they have only just become familiar with.
In order to ensure that hospitals are able to roster consultants on over weekends, this would need hospitals with the sufficient weight of numbers to allow each specialty to have one of their members do weekends and still be able to maintain an adequate service during the week. While the increase in the consultant workforce is to be welcomed, Ireland remains significantly behind OECD averages across all specialties. The position of the IMO is that the consultant workforce needs to be rapidly expanded to meet the needs of the population and its demographics. Also for that consultant to be able to work efficiently, it would need a ‘whole-of-hospital’ response that includes health and social care professionals, nursing staff, as well as maintenance, portering and clerical personnel. For this to happen, we would need a new comprehensive review of the acute hospital system. Like its predecessor, it would likely suggest consolidation of hospitals to match changing demographics as well as efficiency and cost effectiveness of the system.
A new plan would inevitably involve potentially some hard political decisions as to which services will get upgraded and which may get downgraded. These are the sort of challenges that need to be overcome if we are to provide a service that will be able to guarantee patients that they receive the same quality of service no matter what day they turn up to a hospital. Any other plan is basically plastering over the cracks.
As I finish this piece (mid-April 2025), I see the stock market crashing in response to President Donald Trump’s “Liberation Day” and front page warnings of the implications of this for Ireland. I only hope we are as lucky as Mr Gray and find the eyes to see the brighter day.
The IMO AGM takes place on 24-26 April in The Europe Hotel, Killarney, Co Kerry
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