Ask people in Ireland to name groups or professions with real power, and, inevitably, they will mention politicians, perhaps journalists, maybe even lawyers.
Nine times out of 10 they will miss the group that has more power than any of those: hospital consultants.
One week ago this newspaper broke the story of a report on the actions of one of those consultants. The report, by three of the consultant's peers, members of the Institute of Obstetricians and Gynaecologists, set out to examine why this surgeon so often, when performing a Caesarean section ended up performing a hysterectomy at the same time.
The international average for this kind of surgery is one per 2,000 Caesarean sections. The average for the hospital in question was one per 20.
The report found, inter alia, that just under half of these one-in-20 Caesarean hysterectomies represented "unacceptable clinical practice". Not unexpected, given that a British expert had already rendered judgment, at the request of the employing health board, on some of the cases, and had been unequivocal in criticism, not to say condemnation, of the approach taken by the surgeon.
Now here is a situation where whistle-blowing by a nurse led to one investigation by an uninvolved external expert, and one investigation by the umbrella body representing the surgeon's peers, of which he is a member. Both have to differing degrees and using markedly different language, "found against" the surgeon.
Yet the health board involved continues to employ the surgeon. Not only does it continue to employ him, but having presented this latest report to his board on Monday, the CEO announced helplines, counselling, contact schemes to inform GPs: a million and one actions to mitigate the concerns of patients who may, in the light of this latest report, be retrospectively examining surgery which at the time they believed had saved their lives and which they now realise may not have been justified by catastrophic bleeding (as they believed) but which may have mutilated them and ended their chances of further child-bearing without such cause.
All of the services set up to help these women add up to a commendable approach by the health board. Commendable, but contradictory. Why continue to employ someone on whose work two negative authoritative judgments have been made? Why continue to pay someone whose actions have already cost the health board money and will undoubtedly lead to legal actions, costly in their turn? Why continue to keep on the payroll someone suspended by the Medical Council who has, accordingly, not been active within the hospital for six months?
The short answer to these questions appears to be: no choice. The health board is caught between a rock and the common contract. It is on the horns of a dilemma called "clinical autonomy", enshrined in that common contract and in every aspect of the relationship between the employer (in this case, indirectly, the State) and the employee (in this case, hospital consultants).
Clinical autonomy is a phrase with a great ring to it. It implies that if you're a patient in hospital under the care of a consultant, and that consultant says you need X tests, Y surgery and Z drugs, you'll get all of them. It implies that the management of the hospital, or, indeed, the health board, can't suggest the tests be skipped, the surgery postponed and generic drugs substituted for the branded ones your consultant prescribed.
But - look on this picture.
If there had been a proper audit system in the hospital where these Caesarean hysterectomies were happening in such numbers through the years, the discrepancy between its figures and those of the larger maternity hospitals (which, creditably, publish their statistics on their websites) would have been apparent. Questions would have been asked. Problems identified. So what was the health board at, that it had no such audit system in place?
Believe it or not, because of clinical autonomy, they had no power to put such a system in place. Nor have they such power now. Audits of surgical practice are completely within the power of the consultants to set up. If they choose not to the health board has no power to compel them.
The State, through the health board, employs a consultant. But the State, through the health board, has no power to make that consultant show how much of any procedure he does or what the outcome is. If the surgeon says an organ removed had a series of things wrong with it, and Pathology in the same hospital says the organ had nothing wrong with it, hospital management can do nothing at all about the discrepancy.
It appears that even when two separate sets of experts say a surgeon did unnecessary surgery (of a life-changing and mutilating kind) the health board management has no power to dismiss the consultant involved. The State, it would appear, has the power only to sign the cheques.
The autonomy principle, so necessary to privacy and to ethical management of a patient's case, has been inflated into an unbelievably effective method for consultants to defend their territory.
There has been much questioning of quis custodiet ipsos custodes? (who will guard the guards themselves?) in recent times, apropos judges and (prior to that) politicians and public servants.
It is perhaps time the same question were asked about hospital consultants.
I would essay one part of the answer at this point. Whoever guards the guards when the guards are hospital consultants probably should not be their peers alone. The most recent report, illuminating as it may be about the cases examined, is at the same time sadly amusing in its contradictory but very evident desire to look on the bright side. Nowhere is this more obvious than in its portrayal of the maternity unit as well run.
Now, according to this same report, this maternity unit was doing 100 times the international rate of a particularly mutilating surgery. At least half of these surgeries as performed by the leader of the unit, according to this same report, were unjustified and undertaken without either time being given to consideration of other options or consultation taking place with other experts.
When I wrote about this issue last December I said the information uncovered by the investigations should be shared publicly so that healthcare could benefit as a result. Surely now is the time for swift and decisive action.