The issue of consultant productivity is receiving increasing political focus. David Lynch reports
If you created a word-cloud to represent the discussion and debate within Irish healthcare over recent months, “productivity” would certainly stand out – large and bold.
The term is referenced across the pages of the HSE National Service Plan (NSP) 2025 and has been on the agenda of HSE and Department of Health meetings. For instance, minutes from the Sláintecare programme board in September highlighted the “strong uptake” of the public-only consultant contract (POCC) and its role in “improving productivity” across the health service.
In November, the Medical Independent (MI) reported that over 60 per cent of consultants in the public health service held the POCC.
The NSP 2025 includes a section titled ‘Productivity Reporting Model’, outlining two key commitments related to consultants.
First, it states that consultants will receive monthly data comparing their outpatient volumes to those of their peers within the same specialty.
Second, the national clinical programmes and clinical leads will be engaged to recommend a standardised approach for defining the “optimal outpatient throughput” that consultants should deliver each week.
The HSE informed this newspaper that it currently publishes an outpatient attendance dashboard, which tracks outpatient activity, including the monthly average number of appointments across 27 hospitals. The information is categorised by specialty, health region, and consultant. Consultants are identified using anonymised codes rather than names.
A spokesperson confirmed that this year, national clinical leads “will be engaged” to help determine the “optimal” weekly outpatient throughput for consultants.
It is not only in HSE documents or Departmental meetings where the topic features prominently.
“Productivity” has been regularly referenced by both the former Minister for Health Stephen Donnelly and his successor, Minister Jennifer Carroll MacNeill.
On 5 November, the then Minister Donnelly wrote to the Executive’s Chair Mr Ciarán Devane stating that the HSE’s “overarching objectives” for 2025 should be improved efficiency and “increased productivity”, as well as advancement in quality of care.
In the same letter, the Minister wrote in detail regarding consultant productivity (see panel p4).
Last month, the new Minister brought a memo to Government regarding emergency department crowding. Minister Carroll MacNeill said the POCC needed to be used to increase the provision of evening, extended out-of-hours, and Saturday rostering of consultants (see panel p5).
In response to the NSP 2025 and its productivity commitments, the Chair of the IMO consultant committee last month told MI that the Organisation would prefer metrics to also take into account quality of service.
“You could have someone who is putting through high numbers [of patients], but is providing [a] less quality service, compared to someone who is putting through lower numbers,” said Prof Matthew Sadlier.
Therefore, a focus on quality of service is vital. However, Prof Sadlier warned that the Irish health service has traditionally been “very poor” at measuring this area.
Productivity analysis needs to reflect the specialty involved, local circumstances in which consultants work, and the services available to them.
He argued that not only is the concept of a pure “demographic headcount… not good”, but in other jurisdictions has been “shown… to be actively dangerous”.
Prof Sadlier said that no system should encourage doctors into “rushing patients through” or become a “tick-a-box” exercise where patients are seen in as “short a period as possible”, with a potential negative impact on quality of care.
He warned that a “slavish adherence to productivity targets… could engender a culture of low-quality care” with the focus solely on the number of patients seen.
If a system of productivity analysis exposed any difficulties with a consultant, Prof Sadlier said the IMO hoped that a proactive and problem-solving approach would be taken.
He said the Organisation was “obviously not against… the concept of quality assurance and productivity analyses”, adding that data collection was at the core of medicine.
Commenting on the same NSP 2025 measures, an IHCA spokesperson told MI that a “deeper level of productivity analysis, involving an assessment of actual capacity in place for the time periods analysed, may be required”.
“For example, it is accepted that infrastructural access or CNS [clinical nurse specialist] inputs may need to be factored into any analysis, given the impacts these can have on such metrics.”
The spokesperson also struck a positive note, highlighting promises within the Programme for Government to provide investment.
These measures “should make a meaningful impact” in addressing longstanding deficits in terms of outpatient waiting times, mental health and women’s health, hospital beds, and other infrastructure.
The Association believed the formation of the new Government represented a “significant opportunity” to advocate and implement reform and expansion of the acute hospital system. The Association pledged to approach relations with the Government, the HSE, and the Department of Health “in a spirit of constructive dialogue” in order to find solutions to problems facing the health service.
The IHCA’s position is that no patient should be on a waiting list for more than six weeks. This objective is “realistic when looking at other EU countries”.
“To achieve this, the very obvious shortages of hospital beds, theatres, diagnostic, and other facilities across the country need to be addressed, together with filling the hundreds of consultant posts that are vacant or filled on a temporary basis.
You could have someone who is putting through high numbers [of patients], but is providing [a] less quality service…
“If the new Government provides the essential resources and capacity to treat our patients on time, consultants will deliver an effective and efficient health service for all. Consultants have and will continue to work with their clinical directors to achieve these shared goals.”
Some doctors believe the exact detail of the productivity stats used will be crucial.
Prof Sadlier highlighted that ‘internal waiting lists’ may not always be captured by official HSE data.
He gave an example from his own specialty where someone might be counted on the waiting list to see a psychiatrist. However, after their first appointment, “they may be referred to a psychologist or someone else in the team.”
“But that doesn’t get externally measured and reported [within waiting list data] even though they might be waiting two years, for example.”
He added that on “the other end of the scale” the metrics on discharge can “also be problematic” if “quality is not attached to it”.
“So, if it’s discharge from hospital, you might [need to] look at how quickly people are being readmitted, etc,” he said.
‘Relentless’ focus on productivity in 2025, HSE Chair promised Minister
This year will witness a “continued and relentless focus on productivity” to improve healthcare access and outcomes, the HSE Chair informed the then Minister for Health Stephen Donnelly in November.
Productivity – particularly in relation to consultants – was a significant theme in letters between Minister Donnelly and Mr Ciarán Devane prior to the publication of the HSE National Service Plan (NSP) 2025 in January.
On 5 November, the Minister wrote to the HSE Chair outlining that the Executive’s “overarching objectives” for 2025 should be improved efficiency and increased productivity, as well as the ongoing focus on improving the quality of care.
In the letter, obtained under Freedom of Information legislation, Minister Donnelly recalled that he had met the HSE board in early June. At the meeting, he presented data “demonstrating a significant drop” in the average number of outpatient visits per whole-time equivalent consultant within the health service.
“This has had a serious impact on access,” the Minister wrote. He added that the HSE needed to ensure more patients were seen by specialists and “deliver further reductions” in waiting times commensurate with the increase in funding and staffing.
He sought a “standardised approach” to recommended outpatient throughput to be developed with help from the national clinical programme leads.
A commitment to this effect was later included in the final NSP 2025.
“There will of course be exceptions due to clinical complexity, sub-specialisation, and other factors,” wrote the Minister, “but at the very least there should be clear benchmarks/targets recommended by our clinical leaders.”
The Minister also sought monthly data for consultants to show how their outpatient data compared with their peers in the same specialty. This commitment is also included in the final NSP 2025.
Minister Donnelly wrote that, as part of this productivity drive, there must be a “decisive shift” to an extended working day and more weekend services. He outlined that the public-only consultant contract (POCC) should be “optimised” in this regard.
He told the HSE Chair that the POCC was proving attractive, but there needed to be “better quantitative data” demonstrating how the contract was being used to benefit patients.
He wanted the HSE board to ensure that a “comprehensive plan” was in place to monitor and measure the value gained as a result of the implementation of the POCC.
“The board should examine this data and ensure that the contract is being fully implemented as intended.”
The Minister also wrote that the taxpayer “is paying a large sum of money” to ensure private practice is phased out of our public hospitals.
“The board must also ensure there are systems in place to monitor the reduction in private activity and the consequent increase in public activity as a result of POCC implementation. The board must provide evidence demonstrating progress in this regard throughout 2025.”
In his reply on 26 November, Mr Devane wrote that the HSE board and senior leadership team was “committed to optimising value for the public funds entrusted to us while delivering high quality, safe, and efficient services”.
“2025 will see a continued and relentless focus on productivity for the purpose of improving both access and outcomes for the public.”
Mr Devane also noted that population health needs were rising as a result of demographic changes. He said demand for person-centred and timely services was growing. “While there has been significant investment in recent years, cost drivers for the delivery of health and care services in a global context are increasing.”
A new Minister with renewed emphasis on rostering and discharge
Less than a month into her role, the new Minister for Health Jennifer Carroll MacNeill announced she had brought a memo to Government regarding urgent and emergency care.
Minister Carroll MacNeill cited “two problems” in relation to the issue. The first was the capacity deficit in the hospital system. The second (and the main focus of the Department press release on 18 February) was the increased numbers of patients on trolleys, especially the spikes after weekends – most notably following the St Brigid’s Day bank holiday weekend.
According to the Minister, this level of hospital congestion had not been seen since January 2023, and she partly attributed the situation to low weekend discharge rates.
The Minister brought hospital data to the Cabinet on the issue. “Recognising that this is in large part connected to the presence of senior decision makers on site, I requested an analysis of the consultants rostered over the same period,” said the Minister.
“It is clear in the hospitals for which we obtained initial data that approximately 10 per cent of consultants were rostered – either on-call or on-site. This is not enough.
“Of course, other senior decision makers to support consultants are needed, but clearly consultants are the clinical lead and indeed the cultural lead of every hospital.”
Given the public-only consultant contract (POCC) provides for evening, extended out-of-hours and Saturday rostering, she said “attention must now focus on realising the benefits” of the contract. This could be done by increasing productivity and maximising the use of hours in the contract to enhance patient care and increase access to services in the evenings and at weekends.
She requested the HSE to provide a “deeper analysis” of hospital consultant rostering in all acute hospitals. This should include focused analysis of the future rostering of senior decision makers in the evenings, on weekends, and public holidays.
The Department told this newspaper that the HSE would report further data to the Minister following analysis of the March bank holiday weekend.
In response to Minister Carroll MacNeill’s comments, an IHCA spokesperson told the Medical Independent that it “welcomed” the new Minister’s “focus on this important matter”.
“Patient flow is central to the delivery of medical care and the overall functioning of our hospital network.” The spokesperson added that hospital consultants are medics, not administrators, and that consultants do not have the ultimate say on rostering.
Noting that over 60 per cent of consultants are now employed on the POCC, the spokesperson said the IHCA was also “keen to further understand the analysis referenced” by the Minister.
Also responding to the Minister’s comments, Prof Matthew Sadlier, Chair of the IMO consultant committee, said that consultants are not the obstacle to extending routine health services over the weekend. He warned that serious investment in staffing and infrastructure, as well as a fundamental change in how hospital care is delivered, are all required to support such a move.
“The reality is that almost all consultants are currently on rosters which involve covering unscheduled care (ie, emergencies) on weekends,” said Prof Sadlier.
As most consultants have signed up to the new contract, it is “evident” that there is an appetite amongst consultants to provide enhanced care over weekends.
“However, for this to be effective and produce meaningful results there would need to be an uplift not only in consultant numbers, but also amongst all other staff groups within the hospital. Just rostering consultants at weekends in the current situation would just result in significant gaps in the service from Monday to Friday.”
Prof Sadlier said that consultants wanted to see a reduction in trolley numbers in hospitals and should not be blamed for the slow discharge of patients over weekends.
“For patients to be discharged safely over weekends, we would also need community services to be available. For example, these include stepdown units, community pharmacies, primary care facilities, meals on wheels and more, being in a position to provide support on a seven-day basis. Often patients are identified for discharge, but the limiting factor is outside of the hospital.”
“The last thing we want to do is discharge patients too early, which can lead to early readmission and in some cases adverse outcomes and readmissions.”
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