Consultants – gaming the system?


Sir, – The recent focus on the 2008 contract with consultants appears to be strangely asymmetrical. Contracts, by nature, impose obligations on both parties. The doctors’ commitment to an 80/20 split of public/private practice is almost exactly observed, at a macroeconomic level. And those in clear breach of contract clearly ought to be taken to task.

There is little or no discussion of the failure of the Government to adhere to its commitments, though. These amount to specified levels of payment, and to the establishment of co-located private hospitals. It seems perverse, though unsurprising, that the group honouring their commitments (which includes me) is the one being pilloried. Difficulties recruiting and retaining staff, and morale, are, of course, unlikely to be helped by this baseless vilification. – Yours etc,



Co Cork.

Sir, – There can be no mitigation or excuse for failure to deliver the best possible care that resources allow for public patients. On the aspiration to exclude private patients from public hospitals, it is worth considering some perhaps unappreciated consequences. The HSE estimates that approximately 20 per cent of funding of public hospitals is derived from private insurance and direct payment by private patients. In the absence of this private patient activity and its payment to public hospitals, the expectation is that it will be replaced by public patient activity at an additional cost. Thus to maintain the present level of public hospital activity wholly for public patients would require increased annual funding of public hospitals by by up to €700 million, as recently acknowledged by the Taoiseach. This represents approximately 5 per cent of the current HSE budget and 15 per cent of the present HSE allocation to acute hospitals.

This letter is not intended to warn against the abolition or reduction of the presently approved public/private patient mix or the currently occurring level of patients awaiting discharge from public hospitals, but it is intended to alert to their very considerable financial consequences. This should be considered in the context of the urgently required and planned increased investment in general practice and community care. Healthcare economists are best placed to predict the costs of these changes from current practice and their likely effects on maintenance of current hospital activity, such as the possibility of ward closures and the effects on the provision of comprehensive community care, the availability of new drugs and on other public services.

The Minister of Health has established a task force to review these issues and its recommendations will of great interest. – Yours, etc,


(Retired Public

Hospital Consultant),

Dún Laoghaire, Co Dublin.

Sir, – For many years Irish medical graduates have had to resort to emigrate in order to seek training places abroad following many years of dedicated service at junior level in the HSE due to a lack of training places. A reluctance to expand certain speciality programmes due to a perceived threat to private practice and vested interests has influenced this.

It is now incumbent on the HSE to attract this talent home. The 2008 contract has failed to do this as consultant positions have not been adequately supported. Ideally newly advertised positions should be properly resourced in order to attract high-calibre candidates rather than temporary locum positions.

A more accountable system, similar to that in the NHS in the UK, allowing payment only for allocated work hours or defined programmed activities, including education of juniors and engaging in service improvement, should be considered. Separately, specific accountable hours for those wishing to pursue private work off-site may help to address the consultant manpower deficiency and address the imbalance. – Yours, etc,


Eccleston, Liverpool.

Sir, – Rósín Shortall’s view (“Stop consultants gaming healthcare system”, Opinion & Analysis, November 22nd) that public hospitals were set up to care solely for public patients is wrong. Public hospitals exist to care for the public at large and that is the basis of the “public” designation. The VHI was established largely to indemnify people with incomes above a threshold, at which they became liable at that time to pay for their care in public hospitals.

Does she also not understand that consultants take significant salary reductions in return for rights to charge private patients in public hospitals? They are therefore not already paid for this work, as she implies.

There are problems of perverse incentive which are better managed in some hospitals than in others. However, there are also issues of inefficiency, lack of capacity and lack of specialists, all of which contribute to unacceptable waiting times for public patients.

Unfortunately, the greater any success in improving access for public patients, the lower will be the incentive to have private insurance which allows people to access care elsewhere. This will increase demand for public care in proportion to success achieved. – Yours, etc,


Dublin 15.

Sir, – A significant number of hospital consultants have been receiving taxpayers’ money for hours never worked. Is this not the same type of cheating as perpetrated by social welfare cheats? Is anything being done to have this taxpayers’ money returned to the exchequer? – Yours, etc,


Malahide, Co Dublin.

Sir, – Well done to RTÉ for once again highlighting the questionable behaviour of some consultants in the HSE.

But why do all these scandals have to be “discovered” by the investigative zeal of RTÉ? – Yours, etc,


Dublin 3.