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Secretary General of the IHCA Mr Martin Varley writes that the potential is there to agree practical plans and workable solutions to address the capacity deficits and reduce the impact of further waves of Covid-19
Even before Covid-19 hit our health services in March, our public hospital system and the patients who rely on them for a service were in an extremely exposed position because successive governments didn’t address gaping capacity deficits over the past decade. The glaring deficits in hospital beds and consultants have left the country in an extremely perilous situation facing into potential future Covid-19 waves, on top of the enormous increases in hospital waiting lists and the escalating demand for hospital care.
The Government needs to provide increased beds and other facilities in public hospitals and end, as a matter of urgency, the salary discrimination against consultants appointed since 2012, so that hospitals can fill hundreds of vacant permanent consultant posts.
There is an insufficient number of hospital consultants, which is leading to record and unacceptable waiting lists. The number and the length of lists have disimproved, while around 500 permanent consultant posts have failed to be filled over the past number of years, because of a flawed Government decision.
The number of people on public hospital outpatient waiting lists exceeded 610,000 in August, which is a two-thirds increase on the 364,000 waiting six years ago. The number waiting over 12 months now exceeds 243,000, compared to 41,000 six years ago.
There were over 77,000 patients on inpatient and day case waiting lists in August, which is nearly double that of 2012, while over 17,000 are waiting for longer than a year, compared with 386 in 2012.
Ireland has the lowest number of hospital consultants per 100,000 of population in the EU. We still don’t have the 3,600 consultants recommended in the Hanly Report by 2013. When adjusted for population increases in the interim, the revised equivalent would be closer to 4,500. The National Doctors Training and Planning unit’s recently published report, confirms that there will be a requirement for 50 per cent or more increase in consultant numbers in most hospital specialties by 2028.
The decision to impose discriminatory salaries on consultant appointees since 2012 has proven to be a false economy. Patients are deteriorating clinically on unacceptable waiting lists, resulting in longer and more expensive hospital lengths of stay and poorer outcomes. In addition, medical agency staff costs have more than doubled since 2012, increasing by €50 million per annum and the cost of clinical indemnity has more than quadrupled, increasing to approximately €180 million per annum.
The increased costs are multiples of the expected saving arising from the imposed consultant salary cut. In view of the damaging impact of the persistent consultant recruitment and retention crisis, it is past time for the Government to restore pay parity for consultants appointed since 2012, so that they are paid the salary applicable to their colleagues.
The 2008 consultants’ contract contains the very significant core principle that: “Both the consultant and employer recognise that the relationship must be founded upon mutual trust and respect for each other.’’ Also, the contract, which was negotiated between IHCA representatives and the HSE, Department of Health, and the Department of Finance, provides that its terms and conditions will be reviewed by the same parties.
It is unacceptable that the Minister for Health in 2012 unilaterally breached the contract principles and provisions that had been agreed to by his predecessor in 2008. The breach, which imposed a 30 per cent salary cut on consultants taking up the contract since October 2012, has been extremely damaging for many reasons including the high levels of international competitiveness and mobility of hospital consultants.
It is expected that the current Government will rectify these errors based on the commitments and statements by the Taoiseach on the Dáil record, the Minister for Public Expenditure and Reform and the Minister for Health while in opposition during 2018 and 2019. It is also encouraging to note the strong position taken by the Taoiseach, Micheál Martin, when he publicly outlined his annoyance and anger at the fact that the UK was contemplating breaching an agreement it had entered into with the EU and its Members States. The Taoiseach’s respect for agreements and the need to maintain trust is well based as it is the foundation on which agreements are entered into and on which progress is advanced in any walk of life.
These principles need to guide the current Government in immediately ending the inequity by honouring their own commitments and the terms of the 2008 consultants’ contract in full for all consultants including those who have taken up the contract since 2012. It is also critically important that the Department of Health and Government Ministers frontloaded the expansion of public hospital capacity, in terms of acute hospital beds, ICU beds and other facilities.
This requirement preceded Covid-19, as has been confirmed in the 2018 Health Capacity Review, which recommended, at a minimum, that public hospital bed capacity needed to be increased by 2,600 within 10 years.
In addition, it recommended the need for an additional 4,500 community and step-down beds. The review also outlined if community services were not expanded the required increase in public hospital beds could be of the order of 7,500.
However, the pace of expansion has fallen behind and not enough has been achieved in the interim in expanding capacities in public hospitals and at community level.
The HSE commissioned 2009 Prospectus ICU Report recommended that the 289 ICU bed capacity needed to be expanded to 418 beds within a year and doubled to 579 ICU beds by 2020. This contrasts starkly with the current capacity of about 280 ICU beds. Failure to implement the Prospectus recommendations and advance the Capacity Review recommendations more rapidly left our public hospitals extremely exposed to the Covid-19 pandemic.
Despite the odds, consultants and their teams in hospitals managed to limit the extent of the damage of Covid-19 to less than had been feared at the outset. However, public hospitals are now entering the autumn, winter and spring still with overwhelming capacity deficits which create major risks in providing day-to-day urgent public hospital care in addition to the high probability of further waves of Covid-19 infected patients who will require hospital and ICU care at the same time as the winter surge.
The ongoing capacity deficits are causing horrendous delays and problems for our public hospital patients and if the deficits are not urgently resolved they will create even more shocking delays for patients over the winter and spring.
There is huge potential to agree practical plans and workable solutions that will address the capacity deficits and in turn resolve the waiting lists and reduce the impact of further Covid waves. The first and obvious step for Government is to end the salary inequity imposed on consultants taking up contracts since 2012, so that hospitals can fill the 500 vacant permanent posts. This would have a massive impact in reducing waiting lists for outpatient, inpatient and day case appointments. The consequences of not addressing the consultant recruitment and retention crisis is for the Government to perpetuate and exacerbate the deterioration in public hospital capacity to provide care to patients.
The country’s population has grown to almost five million based on CSO data, an increase of 492,300 compared with 2008. The number of people over the age of 70 has increased more significantly. There is now an urgent need to accelerate the expansion of our acute hospital capacity. The winter ahead will be more challenging than any other because of the risk of further Covid waves, backlogs, and record waiting lists.
While the early publication of the HSE’s Winter Plan 2020/21 is welcome, it is disappointing that the increase in beds provided for is less than will be needed and it has failed to make provisions to resolve the consultant recruitment and retention crisis. These are the essential fundamentals to provide quality hospital care on time and end the provision of care to admitted patients on trolleys and growth in unacceptable waiting lists.
The Government must also address the situation in relation to clinical indemnity and the law of tort concerning such cases. The failure to put in place a system for pre-action protocols to reduce delays and costs in settling cases is disappointing, especially as State Claims Agency clinical indemnity costs have increased steeply, at significant cost to the health budget.
Indemnity for practising consultants has more than doubled, quadrupling for some specialties, since to 2012. These cost increases make Ireland much more costly to practise medicine and provide care to patients than most other countries.
The new Government and Minister for Health take over responsibility for the economy and the health services in very challenging times. Through engagement there are opportunities to rectify the mistakes of the past decade. The Association will be engaging regularly with them to assist with the process to address the capacity deficits in our hospitals.