Dismaying stories of long waits in casualty departments and patients lying on trolleys waiting for beds owe much to hospital cutbacks and staffing problems, but they are also a consequence of the way hospital doctors work.
Hospital consultants are fighting tooth and nail in the Medical Manpower Forum against changes in their work practices which could go a long way to shorten public waiting lists and undo the logjam in emergency departments. Like the taxi-drivers who resisted hackney cabs, they want to maintain their lucrative monopoly, despite public demands for better availability and a different kind of service.
Under present arrangements in hospitals, it is young doctors in training - non-consultant hospital doctors (NCHDs) - who see most public patients referred for specialist appointments by GPs. People who visit accident and emergency departments are also seen by NCHDs in most cases.
The public hospital service is largely staffed by doctors in training, many from overseas. They carry out most emergency work. They are nominally supervised by consultants, but no one monitors the consultants' working hours. In theory, consultants work 33 hours a week serving public patients; in reality, they may delegate to their juniors without anyone questioning their absence.
In 1989 the Commission on Health Funding said some consultants did not fulfil their responsibilities to public patients because of the opportunities to make more money from private practice. It recommended that a system of monitoring should be introduced. The medical organisations are currently fighting the latest attempt to achieve this by the Department of Health.
The Medical Manpower For um was established in 1998 by the then minister for health, Mr Cowen, in response to the problems in hospital medical manpower, with the brief of suggesting career structures which would retain Irish graduates and deliver better medical care. It brings together representatives of the medical profession and health administrators.
All parties at the forum agree more consultants should be appointed, but there is substantial divergence on how they should work, the forum's unpublished draft report reveals.
The Department wants more consultants rostered to be available around the clock to public patients in hospitals, and a much reduced dependence on junior doctors. The Irish Hospital Consultants' Association is arguing for the creation of 1,000 consultant posts - a 70 per cent increase - without fundamental reform of their working practices.
The IHCA does not represent the views of all consultants, however. Prof Muiris FitzGerald of UCD, who is also a consultant physician at St Vincent's Hospital in Dublin, believes that simply adding extra consultants who are allowed unlimited private practice "would merely consolidate what the public perceives as a two-tier system of medicine".
Private patients - whether at outpatient clinics or in hospital - are generally treated personally by consultants, while public patients receive much of their treatment from NCHDs.
"Over 80 per cent of doctors in acute accident and emergency departments throughout the country are in their earliest years of training and are inadequately supervised by a sufficient number of trained senior doctors. Over 80 per cent of patients seen at public out-patient clinics are seen by NCHDs and not consultants," according to Prof FitzGerald.
Thus seriously ill patients are referred by experienced GPs to accident and emergency departments where eight times out of 10 they are seen by very junior doctors on a brief training rotation.
Eventually - sometimes "anunacceptably long number of hours later," according to Prof FitzGerald - a decision may be made to admit them to hospital. Major decisions about treatment must wait for a consultant's twice or three times weekly rounds. Today, 3,000 NCHDs are working in our hospitals - more than twice the number of consultants. One-third of the NCHDs are not Irish. When the last census of NCHDs was undertaken two years ago, almost two-thirds were young, recently qualified doctors in their first three years of training after medical school.
Irish graduates are leaving the hospital system after three to four years, going abroad for further training or taking up other career choices. Hospital services in five of the eight health boards (Midlands, Mid-West, North-East, North-West and South-East) are virtually totally reliant on non-EU nationals.
Of the 237 hospital registrars employed in these five health boards in 1998, 79 per cent were non-Irish nationals. At the more junior grade of house officer (doctors qualified a couple of years) 66 per cent of the 435 employed were non-Irish.
Irish doctors refuse to stay because much so-called training is unsupervised work, running the system for absent consultants. It involves working long hours for poor pay, with dubious promotion prospects. In England, these young doctors can get into well-organised training programmes with a guaranteed consultant post at the end. Their departure leaves Irish hospitals without trained middle-level doctors.
The main reason for the staffing crisis is that the Medical Council has decided to call a halt to the present system. Its president, Prof Gerard Bury, who is UCD professor of general practice, sees "no reason why the State should be denuded of graduates. The haemorrhage could be arrested by making it attractive to stay here".
By refusing to recognise for training purposes hospitals which fail to meet certain standards, and introducing a language and competence test for non-EU nationals, the council is acting as a catalyst for change. The immediate and controversial effect is to present hospitals with an acute staffing crisis. The long-term result, for which the council apparently aims, is a system which trains and retains Irish doctors.
The best existing postgraduate training programmes, according to Prof Bury, allocate one or two years to overseas training while the rest of the time these Irish doctors are contributing to the Irish system.
The council's brief is to ensure appropriate training. The necessary sequel to retain Irish doctors is the provision of an attractive career path - which is central to discussions taking place in the Medical Manpower Forum. The Department of Health's desire to ensure public patients are seen by trained senior doctors intrinsically brings more varied career opportunities for Irish graduates.
Prof FitzGerald has proposed a new category of "specialist" doctor who would be appointed at an earlier age than consultants nowadays, and would have a system of career progression based on achievement. The 1993 Tierney Report on Medical Manpower recommended appointing more consultants and retaining only sufficient NCHDs, engaged in genuine training of shorter duration, to meet future needs for trained personnel. The consultants would change their work practices to become directly involved in emergency services, public patient care and training their juniors.
At the Medical Manpower Forum, the Department has tried to move in this direction, proposing three ideas: a FitzGerald-style "specialist"; or a new contract for all public hospital consultants which would roster them to work shifts including routine weekend and night work - not merely on call but on the premises; or a new category of public hospital consultant where only new appointees would work the rostered shifts. The medical organisations have rejected all three.
The IHCA is offering "flexibility", the Irish Medical Organisation wants to cede no ground before negotiations.
The IHCA defends the current winner-takes-all medical hierarchy of "hands-off" public consultants, assisted by an army of juniors, on the grounds that it produces the best. "Our medical system is on a par with the best in the world - why should we change it?", says Mr Finbarr Fitzpatrick, IHCA chief executive.
A more youthful, Irish-trained, on-the-ground consultant is seen as a lesser breed by the IHCA. Existing consultants have concrete reasons to resist change. Older consultants who have come up the hard way do not want to go back to night work, a concern the forum acknowledges by suggesting such duties might be reduced with age. Some fear that the new category of "specialists", or hands-on consultants, will harvest private patients admitted to hospital while they are on duty - patients whom the NCHDs would have previously treated, while the "on-call" consultant at home received the fees.
Yet there are doctors who are attracted by the concept of more consultants working on a roster with a graduated career structure. They include many women - who account for the majority of medical graduates but only one-fifth of consultants, and who are often not suited to a macho lifestyle involving working long hours for huge rewards. They also include consultants in hospitals outside Dublin who have fewer opportunities for private practice and who find it harder to attract good junior staff - as a result, they must work tough rotas for night call.
"Once it was not seen as a sub-consultant, and if the salary was right, people would jump at a contract which allows them not to be on call to private patients all the time," says a registrar at a Dublin teaching hospital.
"At the moment there is no place in the system for people who don't want to, or can't make it to the top. The Irish system is geared towards making you either a consultant or a GP," according to Dr Patrick Plunkett, consultant in emergency medicine at St James's Hospital.
The IMO and IHCA want this battle to move from the Medical Manpower Forum to negotiations on a new consultants contract and this now seems likely. The IHCA is "prepared to negotiate on on-site rostering if the numbers, pay and conditions are right," says Mr Fitzpatrick.
The negotiations will be a true test of the mettle of the Minister for Health, Mr Martin.