Special Report 55 - Medical Consultants' Contract
Published on 30 March 2007
Summary of Findings
Over 2,000 medical consultants work in public and voluntary hospitals in Ireland. Their terms of employment are governed by a common contract agreed in 1997 and revision of this contract is currently the subject of negotiations between the Department of Health and Children, the Health Service Executive (HSE) and the medical consultants’ representative organisations.
This examination set out to review the extent to which the terms of the existing common contract were implemented in the acute hospital sector and in particular
Monitoring Consultants’ Commitments
The examination found that key elements of the contract were undefined or lacked sufficient clarity to allow for smooth implementation.
There is a fundamental difference of interpretation between the HSE and the consultants about the number of hours to be worked under the contract. The HSE claims that 39 hours per week, inclusive of six hours of unschedulable activities, is provided for, while the consultants contend that a 33 hour week is what was contracted for. It is disappointing that this matter has not been resolved in the ten years since the contract was signed in 1997.
The 33 scheduled weekly hours are divided into 11 three hour sessions, comprising 7-8 clinical sessions and 3-4 flexible sessions covering training, research and management activities. There are also provisions for on-call availability. The contract envisaged the production of schedules which would be agreed with hospital managements in order to show how the service commitment would be delivered by each consultant.
The examination found that, while most hospitals had received work schedules from consultants after their initial appointment to the post, these were not generally subject to systematic review, and in many cases, remained unaltered for many years even where consultants’ delivery of sessions had changed. Most hospitals did not request updated schedules from consultants.
There was a general lack of information available in hospitals to enable managers to satisfy themselves that consultants’ contractual commitments were being discharged. There was a particular difficulty in establishing exactly how flexible sessions are delivered and what gets done during those sessions.
Although there was a belief among hospital managers that many consultants exceed their contractual commitment, this cannot be substantiated in the absence of reliable records.
The contract allows consultants to treat private patients while discharging their obligation to the public hospital. Accordingly, in addition to their salary, consultants receive fees for the treatment of private patients. While there is universal entitlement to treatment in the public hospital system, there is also a policy to limit private treatment in these hospitals to a designated level set by the Minister by reference to bed numbers.
The contract provides that a consultant’s overall proportion of private to public patients should reflect the ratio of public to private beds as designated by the Minister at individual hospital level. Overall, 20% of all beds in public hospitals are designated as private beds. In practice, private patient treatment in public
hospitals exceeds 20% in all three categories of clinical activity – elective, emergency inpatient and day case. To the extent that private patients are accommodated and treated in excess of the designated level, there are implications for equity of access. It also means that less resources than intended are being applied for the treatment of public patients.
There is considerable tension between the sessional nature of consultants’ work and the freedom to engage in private practice which could give rise to conflicting professional responsibilities. There has been no meaningful attempt to monitor the level of consultants’ private practice for its impact on the fulfilment of the contractual commitment within public hospitals.
Firm information on consultants’ existing work patterns is essential to cost effective delivery of consultant services. Ultimately, the attainment of value for money from any new contract will largely depend on how well organisational and system change complements and supports the revised arrangements. Otherwise, there is a risk that the State will end up paying more for, what might turn out to be, the same quantum and quality of service.
Clinical Audit and Risk Management
Clinical audit is a vital element in ensuring that hospital services are provided to the highest quality. One of the obligations of consultants under the 1997 contract was to participate in clinical audit. A corresponding obligation of management was to resource the structures within which this clinical audit could be planned, carried out and reported. There was limited follow through on the obligations set out in the agreement.
No central guidance has been provided to hospitals or regions on the development of a clinical audit programme. Consequently, any arrangements that exist are implemented at local level and to a variety of standards.
The examination found that, while about 80% of hospitals claimed to have some arrangements for clinical audit, the nature of these varied from hospital to hospital. Although several examples of good practice were noted in the course of the examination, clinical audits carried out were not generally part of planned prioritised programmes nor were the results reported to hospital managements or shared with other hospitals. Without appropriate arrangements for reporting of results, it is unlikely that hospitals will be in a position to optimise the benefits from audits. None of the hospitals visited could demonstrate that time was allocated for consultant review and assessment of audit outcomes.
Clinical risk management is currently underdeveloped in public and voluntary hospitals. There are as yet no national risk management guidelines and the HSE has not promulgated standard procedures or best practice for the operation of risk management for the acute hospital sector.
The advent of the State Claims Agency has led to a greater awareness of the importance of risk management and proactive measures have been taken by some hospitals. However, the HSE is of the view that, even in hospitals where risk management appears to be well developed, it is still proving difficult to operate effectively.
While both clinical audit and risk management involve all medical staff, consultants have a pivotal role to play in this area. Consequently, future contractual arrangements should address the obligations of the respective parties and the mechanisms through which clinical audit and risk management will be implemented. Full implementation of a comprehensive national plan is likely to take three to five years.
Consultants and Management
The 1997 contract envisaged an increase in the involvement of consultants in the management of hospital services. Principally, it provided for the creation of management boards with consultant representation to run each hospital and the establishment of unit groupings.
The examination found that nearly all the acute hospitals had full executive management boards or similar structures in place with varying degrees of consultant involvement. However, at the unit grouping level, more refinement is needed in most cases before the arrangements could be regarded as effective clinical directorates.
A Clinicians in Management Initiative launched in 1998 and which was allocated €10 million in the period to 2004 had limited success. A report on the initiative in 2005 recorded that full clinician involvement in decision making and in the management of resources was not yet the norm. While considerable management change has taken place since 1997, the pace of change has not been as fast as might reasonably be expected in a ten year timeframe.
The failure to evolve and implement a model that integrates responsibility for resources, activities and outcomes was a factor that contributed to the failure to activate the key terms of the 1997 contract in regard to monitoring commitments and clinical audit.
Overall, any new contractual arrangements need to specify the administrative and governance changes that are required to achieve effective implementation and be underpinned by a change management drive. Moreover, it would be desirable that the arrangements provide for a verification process to ensure that the agreed change envisaged is delivered in accordance with action plans tailored to the circumstances of individual hospitals.