Saving lives, losing respect: how 'consultant' became a dirty word

Their work is demanding and unforgiving, but medical consultants are routinely characterised as arrogant, overpaid and greedy. Why do people no longer always look up to the profession?

'EVERYONE HATES consultants – except for their own," says one member of the profession, his body jaded after another 90-hour week and his brain yearning for a hit from the cigarettes he gave up, again, only a few months ago.

"They forget the long years of study, the longer years of trainee pay, the all-through- the-night shifts. They ignore the mountain of debt, the overheads, the high insurance costs. I understand it: people need someone to kick – and, as far as the politicians are concerned, it had better not be them."

Somewhere along the way, "consultant" has become a dirty word. "I feel increasingly ostracised," says a younger specialist. "I'm still proud to be a medical consultant, but in certain company I wouldn't be openly acknowledging the fact."

Medical consultants are in the news again, most often portrayed as a recalcitrant bunch of high-earners fighting tooth and nail to hang on to their privileges when the health budget is a runaway train. Their representative bodies are in the throes of a dispute with Minister for Health James Reilly over his plans to change work practices, cut allowances and reduce the salaries of new consultants.

With the Irish Hospital Consultants' Association refusing to play ball by attending the Labour Court, the Minister is now waving a big stick by threatening wage cuts for existing staff.

But beyond the industrial-relations dispute, there is a broader assault on a once-invincible profession. In a society that is in financial crisis, consultants are now bracketed with "fat-cat lawyers" and other high earners in the search for culprits. Within the health services their hegemony is increasingly challenged by a new breed of nonmedical managers and the ever-more assertive nursing profession.

Once, consultants such as Maurice Neligan and Risteard Mulcahy were feted throughout society, respected for their views and honoured for their work. Now, the ordinary person on the street would be hard pressed to name a single well-known consultant.

Michael O'Keeffe, an ophthalmologist who is the only specialist to regularly argue the case for his profession in the media, puts this new-found silence down to a "gagging clause" inserted in newer consultants' contracts since 2008 that makes his younger colleagues afraid to speak out. O'Keeffe isn't a member of the IHCA or the Irish Medical Organisation.

The case for the prosecution runs like this: consultants are among the highest-paid people in the public service, many of them earning more than the Taoiseach; they were handed big pay rises in 2008, just as our financial affairs started to go haywire; many combine work in public hospitals with private work in public and private hospitals; at least some of this private work is effectively subsidised by the public purse.

"Obviously, one doesn't tar them all with the same brush," says Stephen McMahon of the Irish Patients' Association. "But some patients we deal with regard their consultants as arrogant, egotistical and indeed deaf. One patient's relative told me yesterday their consultant would have fitted in well in Stalinist Russia. You do also hear patients complain about the level of fees charged. Finally, there is the perception that the fraternity has difficulty being candid about their colleagues' competencies."

In a health service with a huge deficit, the choice may come down to cutting consultants' pay or cutting services. As former minister of state Róisín Shortall summed it up in her Dáil speech last month, "Do we cut home-help hours or cap consultants' wages?"

Last March, the outgoing human-resources director of the Health Service Executive, Seán McGrath, revealed that one hospital consultant received more than €400,000 from the public health service, and up to 500 senior doctors were earning more than €200,000.

He claimed some consultants were able to complete their 37-hour commitment to public hospitals by Wednesday lunchtime and to devote the rest of the week to their private practice, while receiving additional allowances for being "on call".

As for private earnings, it was claimed last year that one specialist received €1 million in fees from VHI in 2010 and that 138 others received more than €300,000 each. About 1,800 consultants shared €386 million in fees for treating privately insured hospital patients in the year to the end of June. This averages out at more than €214,000 per consultant. VHI says no consultant currently earns more than €1 million.

Consultants occupy a unique position in the firmament of Irish health: powerful and independent. Their ability to work in both the public and private systems has been the subject of sustained criticism, most often involving allegations that private patients are fast-tracked relative to the public waiting list.

In the most commonly repeated complaint by patients, it is related how a person languished for months on a public waiting list for an appointment or procedure, but was seen within a week as a private patient. It is also common in the public system for scores of patients to be called for appointments at the same time, leading to long wait times, whereas in private medicine, individually timed appointments are the norm.

The hierarchical nature of hospital medicine frequently leads to situations where entire medical teams wait for a decision from their clinical leader, the consultant. But if that consultant is overworked, or if there are too few consultants, or if the consultant is off doing private practice, the inevitable result is delay in treatment or discharge.

THE VIEW FROMthe profession is quite different. "The difficulties in the health service are not the fault of consultants," says Seán Tierney, a vascular specialist at Tallaght hospital. "There is a perception that consultants are a barrier to change, when in many case we've been driving it."

He rejects the Minister's contention that new work practices can deliver vast savings. "Changing work arrangements won't create more hours in the day. I'm seeing more patients than ever with lower wait times over a 60-hour week."

Yes, he does private work, but he argues that "the patients choose me; I don't choose them". Because there are no waiting lists in his area, access times for private and public patients are similar, although Tierney accepts that it may be different in other areas.

The Minister should be more worried about the drift of consultants to all-private settings, he believes, as his profession is hit by "an unstated public policy in favour of private hospitals".

A senior specialist who earns €160,000 in the public system and has a busy private practice says: "On average, you get €1,000 per operation from insurance. So to earn €500,000 you have to schedule 500 operations a year. That's a lot of work, and you have to cover your secretarial costs, insurance and other overheads – €500,000 is your turnover, not your income."

If consultants are doing private work in public hospitals it is because their managers need the income this work generates, he says.

Although consultants are in the line of fire in public debate, they have their own targets when it comes to the blame game.

"We have administration, not management," says Trevor Duffy, a rheumatologist at Connolly Hospital Blanchardstown, in Dublin. "We need more support and direction in place of checklist-driven control and the counting of widgets."

Duffy started his career in a well-appointed hospital in Geneva; it's a long way from the Swiss clinic to the bustle of Connolly, where 60-hour weeks are the norm. Talk of greater flexibility won't make much difference in such circumstances, but he frets about whether codifying this flexibility won't end up making things worse rather than better.

"If you have to come in at a weekend to do your rounds, you do it, but I'd imagine if in future there are structured sessions you're more likely to say you need an afternoon off during the week."

At present there is minimal absenteeism among the profession, especially compared with other grades in the health service.

Duffy admits to mixed feelings about having returned to Ireland, especially now that colleagues are on the move again to the US and Canada. The lead person for Connolly's bid to build the new national children's hospital, he says the health services are now at a critical point and the right decisions have to be made "not just for now but for the next 200 years".

"I don't think in my working life things have ever been so difficult," says Charles Gillham, a radiation oncologist in Dublin. "Working in the health service is very different, even more than it was just a year ago."

Without complaining, he enumerates the many changes in his working life over recent years. With his colleagues, he now services three hospitals rather than one, with no increase in staff. Maternity leave and sick leave go uncovered. He used to share a secretary with one colleague; now he shares her with five. He used to have a registrar to himself, but not any more.

Yet Gillham works in cancer control, which has benefited from an injection of resources and has notched up eye-catching improvements in patient outcomes. The radiotherapy equipment he now uses is state-of-the-art for any European country.

His working day begins at 7.30am four or five days a week and continues until 6.30pm or 7pm. Three or four evenings a week he takes home work "just to keep up".

He doesn't strictly have to do teaching and research, but in common with his peers these are expected parts of the job, along with ongoing clinical audits.

These days, he must pay the €3,000-€4,000 cost of attending an international conference out of his own pocket. "Pharmaceutical companies will go some way to supporting you, but this is now discouraged by the HSE."

Professionals in other areas will recognise the longer hours, the greater work pressures and the lack of cover, but they are unlikely to be putting people's lives at risk. Ask any hospital doctors about their greatest fear and they will probably tell you that patients are increasingly at risk from the drive to cut costs.

"It is difficult to believe that, with the increasing lack of resources, the lack of nursing and other staff and the very low morale within the health service, patients aren't at risk," says Gillham. "The more stretched we are, the more rushed we are, the less time we give to patients, and that can only be a bad thing."

More and more decisions that are shaping the health service are being made by managers rather than clinicians, he says.
ARGUMENTS RAGEabout how much Irish doctors earn compared with their colleagues in other countries. Last year, an OECD report said consultant pay in Ireland was by far the highest of the 20 countries surveyed. The research was based on 2008 data, and salaries have been cut since, but the findings have been picked up by troika officials.

Comparisons with most other EU countries are of little use, as Irish doctors tend to work in other English-speaking countries. Salaries in Britain's National Health Service start lower than in Ireland, but with time staff can earn considerable performance bonuses.

"We're not competing with the EU to hold on to graduates. We're competing with the US and the UK," says a senior neurosurgeon who has worked in England and Australia.

Increasing evidence that Irish doctors are staying abroad or heading away again. This week, it emerged that Prof Bill Powderly, head of UCD's medical school, and Prof Dermot Kelleher, dean of medicine at Trinity College, are taking up prestigious positions overseas.

As in teaching and across the public service, the Government is opting to slash the salaries of new consultants rather than make a smaller, across-the-board reduction in salaries. Newly appointed consultants will in future be paid €116,000 a year, down €50,000 from the existing salary.

This will give rise to numerous anomalies, as many have pointed out: experienced junior doctors earning more than new consultants, or retired consultants receiving a higher pension than new recruits earn in salary.

So while the grandees of the profession are lucratively employed and availing of the historical perks available, the reality is quite different for newer consultants and will be radically changed for those yet to be appointed.

One fortysomething consultant says that of nine peers who have been appointed in recent years, only two own their own houses.

"They don't expect any more to own the two-storey-over- basement period house or the fancy car, or to send their children to private schools. But they did expect to be able to buy their own house."

Different strokes: What are the two consultants' organisations doing?

The Irish Hospital Consultants’ Association was formed in 1988 as a rival to the established Irish Medical Organisation. Set up initially because of unrest among consultants over tax and waiting-list issues, it appointed the former Fine Gael general secretary Finbarr Fitzpatrick at the helm and quickly established itself as a forceful voice in health and pay debates.

The IHCA claims 1,800 members; the IMO says 800 of its members are consultants.

In the current dispute, Minister for Health James Reilly’s proposals would give clinical directors significantly increased powers to roster consultants to maximise patient throughput and to increase the presence of senior clinicians in hospitals across the day.

Some consultants would continue to work on a Monday-to-Friday basis, across a day running from 8am to 8pm. Others would be rostered on any five out of seven days, including weekends. They will continue to receive on-call allowances.

The IHCA has declined to attend the Labour Court, arguing that it did not need to do so as the issues under discussion were not covered by the Croke Park deal.

The IMO has attended in relation to two specific points of difference. These relate to plans by the Health Service Executive to cut rest-day entitlements and reduce payments to psychiatrists for providing second opinions.

Both organisations object to the Government’s plans to cut starting salaries for new consultants, but Reilly says it plans to go ahead with this change anyway.

Reilly has warned that if consultants do not co-operate with a Labour Court recommendation they could lose the protection of the Croke Park agreement and face possible pay cuts.

Pay and conditions: How much do consultants earn?

A bewildering array of contracts applies to consultants working in the public service, but in general the older the contract the better their terms. Some consultants work exclusively in the public sector; others have contracts allowing them to perform both private and public work; a third group works exclusively in private hospitals.

Most of the 2,500 consultants in public hospitals are on contracts that allow them to treat private patients in addition to the 37 hours a week they must devote to the public system.

About 80 per cent of consultants are on contracts negotiated in 2008 that vary in the amount of private practice allowed.

Type A contracts, for which the salary ranges from €166,010 to €173,243, is public-only practice.

The most popular contract, type B, involves salaries ranging from €156,258 to €158,400 and allows consultants to perform 20 per cent private practice in the public hospitals in which they work.

Type C, with salaries of €136,620 to €145,617, allows consultants to treat private patients outside the public hospitals.

The Government now intends to cut the entry-level grade for newly appointed consultants from €166,000 to €116,000.

Consultants are also paid overtime for weekend work and are entitled to on-call and call-out payments. Allowances are paid to the masters of the three Dublin maternity hospitals and to clinical directors.

Consultants’ public salaries are in many cases augmented by significant private earnings. The VHI says that the average fees paid to consultants for private work in 2011 was €86,000.

Fifty per cent of consultants earned less than €50,000, and 71 per cent earned less than €100,000. One per cent earned over €500,000. In 2010 about 1,800 consultants shared €386 million in fees for treating privately insured hospital patients in the year to the end of June. This averages out at more than €214,000 per consultant.

Case notes Why one doctor feels forced out of Ireland

The Government's decision to lop €50,000 off starting salaries for new consultants will most affect midcareer doctors in their 30s.

Many of them are making plans for their last stage of their overseas training before, they had hoped, returning to take up consultant posts back in Ireland.

Not any more. People like "Beth", a final-year specialist registrar about to take up a training post in Australia, are seriously considering one-way tickets.

"My time abroad was always planned with a view to returning home, but now I'm thinking I might stay over there. The salary cut was the final straw on top of a health system that is going from bad to worse."

In Australia she will work a 43-hour week with no overtime and earn as much as she does in Ireland for working more than 60 hours a week.

"Beth" isn't alone in her outlook; friends from her old class have already moved to Boston and Toronto, and others, even those with families, are looking.

"The old idea was that you acquire new skills internationally and bring them back to Ireland. You might go somewhere where you'd work hard, but it was only for a few years. But people are now planning their overseas assignments for the long term. It's, say, Toronto rather than Ohio."

Her parents don't like the idea of her travelling to Australia, and she worries about not being around as they grow older and about the standard of care they will receive.

After six years at medical school, and 10 further exams, she says she's unwilling to come back to Ireland and be treated as a second-class citizen relative to longer-established consultants. "It's also the fact the doctors are being singled out when other well-paid people are not."