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Towards a consultant-delivered health service

In that context, it therefore makes sense that the ambition of a consultant-delivered health service remains national policy. Whatever disagreements the IMO may have with the Department of Health, we are in agreement with the importance of transitioning to a consultant-delivered service, for the benefit of both doctors and patients.

However, the basic building block of a consultant-delivered service is, quite naturally, consultants themselves, and according to the OECD, Ireland has among the lowest per capita number of medical and surgical specialists in Western Europe.

Given the policy ambition of a consultant-delivered health service, it would seem logical to assume that national policy would be directed at addressing this specialist shortfall.

Unfortunately, the ambition of a consultant-delivered service has, to a quite unprecedented degree, fallen foul of policies which have produced an exceptional consultant recruitment and retention crisis within the public health service.

Some figures are instructive in setting out the scale of the issues that face us:

In 2016, of 84 consultant posts that were advertised, half received two, or fewer, applicants.

Of these 84, some eight received no applicants.

Figures presented to the Seanad would suggest that up to 500 consultant posts are either not filled, or filled on a temporary basis only.

It is worth repeating again that Irish consultant posts, which once would have attracted several dozen applicants and intense competition, are to an extraordinary degree failing to generate much interest in this most competitive of international labour markets.

As part of preparing our submission to the Public Service Pay Commission, the IMO asked members how Ireland had come to this rather sorry pass. The answers that we received paint a worrying picture of a demoralised consultant body:

Over 70 per cent of consultants reported that they felt they could enjoy a more positive workplace culture and environment abroad.

Over 70 per cent of consultants reported that their remuneration would be increased by moving abroad.

Over 70 per cent of consultants felt that their workload would be more manageable if they moved abroad.

We are having trouble recruiting consultants and we are having trouble retaining those that we do recruit. What this means, in the very real terms of dry economics, is that there are insufficient numbers of consultants to meet patient demand. Patients must endure lengthened waits to see a consultant. When those patients do see a consultant, they are likely to encounter a doctor who is compelled to work well beyond their contracted hours to deliver care in a system that sags under the weight of decades of underfunding, and cramped capacity. The inability of many patients to access a consultant in a timely fashion is a key driver of the trolley crisis, albeit one that most policy-makers and commentators have studiously ignored.

Perhaps the nadir in terms of the conflict between ambition and policy came in October 2012, when the pay of new-entrant consultants was unilaterally cut by 30 per cent. While the IMO has achieved the reversal of most of this cut, the impact of so dramatic a decision continues to reverberate. It is not until this cut and the cuts visited upon consultants by the employer’s breach of contract and the public sector cuts are fully addressed that Ireland will start to become a place where specialists will choose to return to take up appointments. Ninety-nine per cent of consultants, as surveyed by the IMO, felt that the 2012 cut damaged the Irish public health service’s ability to recruit and retain consultants. When one considers NCHDs, nine-in-10 said that this cut would be a factor in their deciding whether to practise medicine in Ireland or abroad.

I alluded to the IMO’s submission to the Public Service Pay Commission. The IMO is the only medical representative body that has the right to make a submission to this Commission, and succeeded, through national negotiations, in having medical recruitment and retention considered in module one of phase two of the Commission’s work.

The IMO’s detailed submission called for the restoration of the last part of the pernicious salary cut of 2012 — a cut, let us remember, that was visited on no other group of public service workers. The IMO also called for a commitment to be given that the current terms and conditions of consultants be honoured. It’s difficult to think of any other group of public service workers who would be compelled to go to court to have terms and conditions that have been set out in black and white in their contract implemented.

The Commission is due to make its report in the first half of 2018, and consultants and the IMO will await that report with interest.

We are reaching the time when a decision will have to be made as to whether we still aim for a consultant-delivered service, or whether we will set our sights lower and struggle along with ‘more of the same’. As clinicians, we are interested in the evidence that is presented, and we know that a consultant-delivered service would offer the best possible outcome for consultants, for the doctors that we are training and, most importantly, for our patients.

Dr Peadar Gilligan is Chairperson of the IMO Consultant Committee and incoming IMO President.

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