Bad medicine

As he leaves the HSE after four years as head of HR, Sean McGrath pulls few punches when he talks about the extent of the budget crisis in the health service – and what must be done to effect change

AFTER FOUR YEARS as head of human resources in the country’s largest employer, former Army officer and bank executive Sean McGrath is heading to the World Bank in Washington.

He leaves behind a health service which has undergone dramatic levels of change – more than €2 billion has been cut from the budget, thousands of staff have gone and the system has struggled to maintain patient services in a period of unprecedented turmoil.

However, after nearly a decade of reform, remaining staff face more years of change as the Government seeks to dismantle the HSE and move towards a new system of universal health insurance.

For the past two years, industrial relations in the public service have been dominated by the Croke Park agreement – which guarantees no further pay cuts or compulsory redundancies for staff in return for co-operation with the reform programme.

McGrath has been at the forefront of implementing the agreement in a sector which accounts for one in three people on the State payroll.

However, while he believes the controversial agreement has delivered, he maintains it now needs to move to the next level to bring about fundamental reform, particularly in the light of Government policy of continuing to scale down the numbers on the State payroll.

The numbers employed in the health service are set to fall to 96,000 by 2014 – down from a peak of more than 111,000. To mitigate the effects of shrinking budgets and falling staff levels on patient services, McGrath believes there are only two options – either reduce the amount paid for labour or increase working hours for employees.

McGrath opposes further cuts in core pay – which has already been reduced on average by 14 per cent. However he argues that the €1 billion spent annually in the health service on allowances, overtime and other forms of variable pay will have to be looked at.

He says the existing arrangements for paying time-and-a-half or time-and-a- quarter in certain circumstances, as well as the various allowances currently paid, are no longer affordable. He also maintains that changes in this area would have to affect existing personnel and not just new entrants.

“If you look at the €1 billion of spend year or year. That has to be changed in relation to the price you are paying for it, and the only way you can change the price is to change the rate and the rules. That would mean somebody getting double time for a Sunday [at present] would get flat time, somebody who is working outside of their core hours [of] nine to five up to 8pm would only get flat rate as well or would get no rate – it would be part of an extended roster. People who are getting allowances outside of their normal [arrangements] – those allowances would have to cease.”

Alternatively, McGrath suggests that existing working hours could be lengthened. He says at present working hours in the HSE range from 33 to 39 per week. However, he says those who are the lowest paid are those who work 39 hours per week. He says this anomaly needs to be fixed.

McGrath personally tabled proposals to both the current Government and the previous one to bring all staff up to 39 hours per week, with senior management and hospital consultants working 43 hours. He says this would be the same as bring 4,000 whole-time equivalent staff into the system. Asked about the response to his proposals, he says he was told thank you, but it is technically outside the scope of Croke Park to do this.

“From where I sit, what is technically outside of Croke Park needs to be inside of Croke Park in phase two, or even if there is a review of Croke Park over the course of 2012.”

McGrath says he would not favour cutting the pay of hospital consultants – as set out in the programme for Government. This is a view which seems to be shared by the Minister for Health James Reilly, who has signalled that he supports securing efficiencies and flexibilities as an alternative to cutting pay.

However, McGrath says the Minister’s programme of efficiencies will have to be credible, and “one credible way of doing that would be to ensure that they work additional hours within the system, of which many consultants are currently doing as it stands anyway”.

McGrath is also critical of existing private-practice arrangements for consultants in public hospitals and believes these should be reformed to prevent senior doctors leaving to see their fee-paying patients during the main working week.

“My personal view is that, from the taxpayer’s perspective, having somebody in the system that can go off-site and earn private income within the normal working week is mad. It is not happening in any other public sector organisation nor would it be tolerated in the private sector. We seem to tolerate it here for the income it generates for the public hospitals to the tune of €300 million or €400 million per year.

“Consultants earn very, very significant salaries. If you earn a salary of, on average, €180,000 and you work 33 or 37 hours per week, it is unconscionable that you would be actually allowed to earn the same if not double that within the working week itself.”

“If you wanted to ensure that the public patient is first and foremost within the system, we should be in a position to restrict private practice for consultants to go off site outside of core hours or indeed at the weekend.”

McGrath says that at the moment some consultants finish their public hospital work at lunchtime on a Wednesday “leaving them free on Wednesday afternoons, Thursday and Friday to go off to their private practice

While on average hospital consultants receive a salary of around €180,000 per year (with some academic consultants receiving more than €200,000), McGrath maintains when all earnings are taken into account the overall figures can be far higher.

“On average you would have 400 or 500 consultants earning in excess of €200,000 – which is mad in the time we are in.” He says one consultant earned in excess of €400,000 from the public system, although this may have involved some form of legacy payments.

It took more than five years to complete the last set of negotiations on changing the hospital consultants contract in 2008. However, McGrath says the HSE has found it very difficult to implement this contract.

“Every [time] we have tried to implement it we have found resistance, to the measuring system [for private practice], resistance to the public-private mix, and we have found resistance to the fact that we are actually implementing the contract – which some people did not think we would.”

While health-service management has now proposed invoking the Croke Park agreement to roster hospital consultants over five of any seven days, McGrath also argues that significant changes are required also in rosters for nurses.

He says some nurses can also complete their working week in three days. He says a lot of nursing rosters have “been built up over time to suit the individual rather than the service”.

“Nurses typically have 12-hour rosters and work 8am to 8pm. In Limerick last year, we tabled six-hour rosters – the nurses decided to ballot their members for industrial action.”

He also reveals that management has also been looking at the idea of “split shifts” for some nurses. He says that rather than rostering nurses for 12 hours in one go, “we might need you for four hours, take a break and come back in that evening”. “Patients come in peaks and troughs during the working day. And invariably that is what we need both for consultants for staff and for nursing.”

As he leaves the HSE, McGrath acknowledges the Government has an overwhelming mandate to introduce its proposed healthcare reforms. However, these will take time. In the interim, he says, a current challenge is that there is confusion about accountabilities and responsibilities regarding who is running the health service in many respects.

“Until that is clear and he [the Minister] has put in place the governance and accountability arrangements, it is going to be a difficult place to work”.