System as designed by politicians, not the consultants, lets the patient down
I have never before witnessed, in over a decade of service with the Irish Hospital Consultants Association, such prejudiced and inaccurate consultant-bashing as was contained in a number of the articles written by Maev-Ann Wren regarding our health services.
Neither have I been in receipt of so many complaints from consultants who work hard day and night and at weekends for their patients and who feel that Ms Wren's articles have painted them as greedy doctors who devote their time to private patients and who continue to resist change in order to maintain their own incomes and positions of influence.
I recognise the right of every journalist and citizen to hold a view on any topic but I do not accept that it can go unchallenged when it is riddled with inaccuracies, innuendo, unsubstantiated claims and attributions, to a major degree, to nameless, faceless individuals.
In her first two articles Ms Wren correctly identified many of the root causes of the problems in our health services. Indeed, during the course of an extremely lengthy telephone call we discussed and agreed that in comparison with our EU neighbours and OECD countries, funding and resources in Ireland were towards the lower end or indeed at the bottom of the ladder.
OECD and EU statistics show:
Thousands of beds had been taken out of the Irish system and our ratio of acute beds to population is among the lowest;
Our ratio of consultants to population is also the worst;
Our spending per head of population is very much at the lower end of the ladder. (In this context it should be noted that a significant amount of our health spending should be more appropriately categorised under social welfare.)
On the other hand:
Our average length of stay is the second-lowest in the OECD; Our level of maternal mortality is the lowest in the world, according to recently issued WHO statistics.
Contrary to Ms Wren's innuendo, which was supported in your editorial of October 7th, Ireland is not one of the most dangerous locations in the developed world in which to fall ill. I am not aware of any reputable international medical literature which gives credence to this opinion. In fact, the position in Irish hospitals is quite the contrary.
The standard of hospital medicine is on a par with anywhere in the developed world. The biggest problem is that too many patients fail to gain access to this hospital care within a medically acceptable time-frame. The most obvious examples are the long delays in A&E units, the unacceptably long delays for outpatient appointments and for elective admissions.
Ms Wren excoriates consultants as being the root of all evil in the health services. Their only interest is in private practice; they refuse to renegotiate their contracts; they constantly delegate their public work to junior doctors and their general interest is in maintaining the status quo - or so she claims.
This view would seem to have been supported in your Editorial of October 2nd in which you refer to the gulf between hospital and community care and blame the consultant for the presence of this gulf despite the best efforts of the most "dedicated of administrators".
In 1993 there were just under 63,000 employed in the health services. This figure has now grown to 80,000. Of the 17,000 extra employees, consultants account for 300. We are now at a stage where there are two of your "most dedicated administrators" per medical/ dental employee. We now have 11 health boards, including the ERHA, as against eight in the past. More health boards, more administrative structures, 11 empires and remember - 70 per cent of health expenditure goes on wages and salaries.
Ms Wren seems to have overlooked that the majority of our hospitals are run with a handful of consultants. Let's look at the facts:
Naas: six; Mallow: seven; Roscommon: five; Portlaoise: 10; Dundalk: eight; Castlebar: 17; Wexford: 14; Letterkenny: 26; Tralee: 20; Navan: 12; Mullingar: 17; Cavan: 18; Sligo: 33; Drogheda: 27; Clonmel: eight; Kilkenny: 18; Bantry: five; Nenagh: Seven; Ennis: eight; Ballinasloe: 15; Tullamore: 18; Monaghan: eight and Cashel: five.
Does Ms Wren really believe that the two surgeons in Naas or Mallow or Wexford should provide an on-site service for 168 hours a week? Is she suggesting that the two obstetricians in Wexford, Kilkenny, Tra lee, Clonmel, Castlebar or indeed the single obstetrician in Monaghan or in Dundalk can be in the labour ward for every delivery?
Ms Wren states: "In theory, consultants work 33 hours per week serving public patients etc." Yes, that is the theory but the reality is that they spend up to 60 hours on site and thereafter provide an on-call emergency service. And the nameless, faceless ones will tell us that you find consultants anywhere but with their public patients!
Consultants are in the unenviable position that their work practices and hours are dictated by patient needs and not by their contracts. Indeed, it will be interesting to note how the Working Time Act 1997 will affect our hospital services if, on foot of a recent judgment, this piece of legislation is applied to consultants as well as non-consultant hospital doctors.
Be assured, the association is all in favour of appointing more consultants - 1,000 at least. The probability is that far more will be needed to provide a consultant-delivered service. The decision to increase the number of consultants rests with the Minister for Health. At our a.g.m. last year, two motions were passed unanimously, which Ms Wren and readers may find enlightening in the context of consultants' contracts and private practice.
(1) "That this annual general meeting calls for legislative recognition of the entitlement of elective patients (who have been diagnosed at outpatients to be in need of hospital admission) to be admitted within a maximum of six months in the case of children and within a maximum of 12 months in the case of adults."
(2) "That this annual general meeting calls for the establishment of an independent accreditation system with responsibility for determining baseline facilities, resources and services in both public and private hospitals."
This brings me to the subject of private practice which, according to the articles, would seem to be the main interest of consultants. The allegations made do not match the reality in the hospital ward.
More than 70 per cent of patients are admitted to hospital as emergencies. These patients, according to medical ethics, good medical practice and the law of the land, are entitled to the first available bed without reference to the status of the patient (i.e. public or private) or the category of bed to which they are admitted. The seriously ill public patient will be accommodated in a private room if necessary.
Similarly, the terminally ill public patient will be accommodated in a private room. Patients, public or private, with MRSA, for example, are also isolated in private rooms.
Statistics show that the level of bed occupancy in general runs from 90 per cent to 130 per cent. Yes, 130 per cent every winter, when we have that unexpected flu! As seriously ill medical patients have to be accommodated in surgical wards, elective admissions have to be cancelled.
The volume of private practice in a public hospital is not dictated by consultants. Furthermore, the contention that patients on public waiting lists are somehow exhorted to take out private health insurance is unlikely to be true when one examines the VHI's membership rules.
These rules are quite clear on waiting times for benefit in the case of new members with pre-existing conditions. New member - minimum waiting period: under 55 - five years; 55 to 59 - seven years; 60 and over - 10 years. Without wishing to be cynical, the public patient who is diagnosed as needing a hip replacement and is advised that he or she will be waiting for up to two years, will do better as a public patient than if they were to take out private health insurance.
Ms Wren quotes me as saying the Irish medical system "is on a par with the best in the world". While I have neither a recording or contemporaneous notes of our lengthy telephone conversation, it is my contention that I referred to "medical standards" and not the system.
The system is as has been decided by our politicians and it is the system and not consultants who deny timely access to patients.
Talk to the consultants in the Mater Hospital where 2,000 patient admissions were cancelled last year. Ask the Beaumont Hospital consultants about the 70 beds that are closed at present. Talk to consultants in St Vincent's Hospital where several theatres are closed semi-permanently. Inquire of the consultants in Tallaght, our flagship hospital, where more than two years after it opened, some state-of-the-art theatres have yet to be used. Take a trip to Monaghan and see the state of the operating theatre there. Call to the A&E units in Naas, Cork or St James's any night of the week.
Every year more than 500,000 people are admitted as in-patients to our hospitals; in excess of 250,000 day-case procedures are performed. Just under 2 million outpatient appointments are made and there are 1.25 million attendances at A&E units.
The politicians have decided that there should be over 35 A&E units opened round the clock, 365 days of the year, yet there are only 16 A&E consultants attached to 12 of these hospitals. Is it credible that these 16 appointees would wish to retain the status quo? The IHCA proposed over 12 months ago, that there should be 120 (approximately) such consultants.
The IHCA does not view "a more youthful, Irish-trained, on-the-ground consultant as a lesser breed". We contend that the present cohort of consultants, the majority of whom have gained valuable experience abroad, guarantee a high standard of hospital medicine.
In many instances, it is medically necessary for training purposes to send NCHDs to Britain, the EU or North America. We must not, in our rush to paper over the mistakes of the past 20 years, turn Ireland into a backwater in world medical terms. In every other walk of life, the Irish have gone abroad and returned with experience and skills that have contributed to the Celtic Tiger. More and more people are seeking more and more training and experience to meet the customer needs of the modern world. Why should we now turn back the clock when it comes to consultant training and medical standards?
The public patient is as entitled to the highest level of medical expertise as any fee-paying patient in the Mayo Clinic. The consultant training pathway is long and arduous but is has the benefit of turning out the best at the end of the day. Let's mind the baby while we get rid of the bath-water.
Finally, at this weekend's a.g.m. of the IHCA, which represents 1,280 consultants in practice, the following motions, among others, will be debated: (1) "That this annual general meeting deplores: (a) the nursing, NCHD and consultant shortages in our health services and, (b) the unacceptable delay in publishing and implementing the Medical Manpower Forum Report."
(2) (a) "That this annual general meeting reiterates the right of every citizen to health/hospital services within a time-frame that is appropriate to his/her illness. In supporting this right, the association calls for the provision of sufficient resources to guarantee every citizen admission to hospital within a timescale that is appropriate to his/her illness."
(b) "That this annual general meeting supports the right of every patient to receive treatment in the setting that is most appropriate to his/her needs."
I wish I could have a week-long series in The Irish Times to bring some balance into the health debate. We certainly have problems, and in consultants we always seem to have the scapegoats.
Finbarr Fitzpatrick is secretary general of the Irish Hospital Consultants Association