Negotiations with consultants are critical to the success of the Government's health reform, writes Arthur Beesley, Political Reporter.
The Government's plan to reform the health system pits it against medical consultants in a confrontation that will determine whether the wider revamp succeeds.
Introduced on Wednesday with the Government publicity machine in overdrive, the reform plan amounts to the biggest shake-up of the service in more than 30 years. And consultants, the medical elite, will be asked to renegotiate their contract, which dates from the Haughey era.
Change would be inevitable even if the Government was not setting about a wider revamp of the system. An EU directive on working hours will also prevent junior doctors from working long overtime stints to replace consultants at weekends. This means that about 1,000 more consultants will be needed and they will have to be available for night and weekend duty.
The Government hopes to pay for this by reducing the junior doctors' overtime bill, which this year will reach about €130 million.
Proposals on this were contained in a draft report of the Hanly group on medical manpower, which will be considered by the Cabinet next month.
Renegotiation with the consultants will be complex, but the Minister for Health, Micheál Martin, has the backing of the Taoiseach, Bertie Ahern. The Taoiseach said on Thursday that the Government has not "had a good deal" from the current contract.
However, the changes will have to be managed carefully from a political perspective. Very little can happen in hospitals without consultants and no one wants a strike.
Consultants are among the highest earners in the public sector. The typical professional earns €152,000 a year from public duties carried out in a 33-hour week - and, on average, another €127,000 from private practice. In 1997, the salary for public duties ranged from €73,300 to €90,400.
In a service employing 96,000 people, the 1,500 consultants are a relatively small group. But they are perhaps the single most powerful one too. A well-organised lobby, their significant power is exercised within the medical sector and in the wider political system too.
Consultants' working arrangements became the subject of controversy this week when the head of a special Commission on health financing, Prof Niamh Brennan of UCD, said the terms of the contract shocked her.
Prof Brennan's call for a review of the contract was endorsed by the Government and backed by a separate draft report by the Hanly review group on medical manpower.
The Brennan report, co-signed by the 11 other members of the Commission, highlighted significant weakness in the system. Unhappy with consultants' absence from the chain of financial accountability, she zeroed in on consultants' work in private practice.
She noted that consultants are allowed to conduct private work during the 33 public hours by delegating work to junior doctors.
They can do this because of a clause in the contract which says the requirement to "personally discharge" the commitment to public duties "does not preclude" the consultant from delegation.
"That means the Irish taxpayer is paying twice," Prof Brennan told The Irish Times. "It pays the consultant in the region of €152,000 on average. Then the consultant delegates to the Non-Consultant Hospital Doctor (NCHD). It is likely that that delegation of responsibility to some extent accounts for the NCHDs' overtime."
If comments such as these appear to have struck a chord in the Cabinet, consultants are angry.
"The outcome of the vitriolic attacks by Prof Brennan is that a lot of the goodwill toward reform has evaporated in the last 48 hours," says the secretary general of the Irish Hospital Consultants Association, Finbarr Fitzpatrick.
He sees consultants as scapegoats for the wider malaise in the system and says that an examination of medical records would demonstrate that consultants are doing their job. They believe reform should centre on management structures.
Still, Fitzpatrick says that consultants are willing to enter negotiations to increase the flexibility of their contracts and introduce an element of financial management to their duties. This would require a pay increase.
Where he and the Government are on a collision course is on a proposal to prevent new consultants from carrying out private duties for up to five years. This would help the Government to provide consultant care on a 24-hour basis, seven days a week.
However, political sources accept that the arrival of a large group of new consultants with no private patients would encourage existing consultants to concentrate on their private duties.
Either way, Fitzpatrick says there is no way that consultants would accept a system not based on equality between consultants.
Naturally enough, neither the Government nor the consultants would display their hand ahead of what will be an intrinsically political discussion. What is more, the negotiation will take place in the run-up to next year's local elections, when the Government will want to be seen to be acting on its reform plan.
In an intriguing aside, the Hanly group in its latest draft report says it "explicitly set aside two forces that inevitably influence the shape health services: industrial relations issues and political considerations".
This luxury is not open to Micheál Martin or Bertie Ahern, who must also negotiate the reduction in junior hospital doctors' overtime payments with the Irish Medical Organisation.
Ahead of the talks with consultants, which could take at least a year, political sources say there is an acceptance that reform of the consultant contract will not in isolation fix the crisis in the health service.
By the same token, however, they say that reform without changing the consultant contract will not achieve results. Needless to say, Fitzpatrick rejects this.
At stake for the Government as it embarks on the wider reform initiative are its prospects in the next general election, in 2007. For Micheál Martin, success or failure will mark his chances of leading Fianna Fáil.
Always, in the background, is the debate on funding, the biggest shadow over the reform process. Martin said this week that what is good for the Minister for Health can be bad for the Minister for Finance.
As the public finances tighten, a change in the consultants' contract might be good for the two of them. But if renegotiation is bad for consultants, then resistance is likely.
The stage is set.