Opinion Analysis

Thursday 21 November 2019

John Crown: Inefficiency is name of the game for HSE and troika

It is absurd to think that a focus on consultants will fix ills of the health system, writes John Crown

Our health service provides a near perfect metaphor for all that is wrong in public administration in our Republic, and makes the case far more eloquently and practically than any mere polemicist could for radical and far-reaching reform of our system of government.

In addition, recent events which have occurred on the watch of a minister who was elected on a genuinely reformist platform illustrate the obstacles which have to be overcome if we are to tackle the fundamental problems of our system.

We have recently found out that that waiting lists to see some specialists in HSE-run hospitals can run to several years, in a few cases longer than five years. Yet at the same time one of our finest hospitals -- the Mater Misericordiae -- has closed one of its major elective surgery wards due to budgetary constraints. Other closures will follow. The CEO of another hospital, Tallaght, an institution with some of the smartest doctors around, had to negotiate an overdraft with the local bank branch to keep the doors open.

Yet, while operating theatres and wards are being closed, while numbers of essential support staff are being curtailed and overtime eliminated, the absurd contention is being seriously advanced that the fix for these ills is to ensure that the smallest cohort of hospital specialists of any country in the world, who already see, assess, treat and operate on more (many times more) patients than their international peers in any other western nation, need to work more efficiently.

The reality is that hospital administrators, the HSE (Health Service Executive) and the Department of Health need inefficiency. Inefficiency makes sense when you are working to remain in the constraints of a fixed budget. Inefficiency keeps you under budget.

Inefficiency keeps troikas happy. Troikas don't care about waiting lists or mortality rates. They just care about the total spend. A bed occupied by one patient who is waiting a week for a scan that should be done on the same day is a cheaper bed than one which has been used to accommodate five patients each having one-day admisssions for day-case operations. What makes troikas happier than underused beds? Closed beds make them ecstatic.

These anecdotes perfectly illustrate the problem at the core of our hospital system. There is no linkage between activity and reimbursement. There is no incentive for efficiency. The only way the system can react to increased demand is to curtail service.

That explains the closures. QED. End of story.

Next question -- why do we have so few senior specialists? It is repeated so often as to be a widely accepted truism that it must be due to those consultants who are already in posts, operating a closed shop, blocking the appointment of economically threatening new entrants. Well, there is a closed shop. But it is imposed not by doctors but bureaucrats and politicians. Every organisation representing the different hospital specialities is clamouring for additional appointments. Note to commentariat -- the group who block the appointments are the HSE.

"Oh," we are told, "it's because Irish consultants are paid so well -- we can't afford more." We are well paid -- over the course of a career about the same as a British consultant (they start lower but get career-long increments and awards while we stay on our entry-level). Newly appointed Irish consultants get paid much more than entry-level continental consultants, but they are appointed to the post at a stage when their Irish contemporaries are still non-consultant junior doctors. In most continental countries, as they advance and become "department chairmen" (a fairer comparison to our consultants) they gain rights to private practice similar to their British and Irish colleagues.

It should also be noted that when Irish consultants worked for smaller salaries the bureaucrats still blocked appointments. Salary is a small component of the cost of a consultant. The main cost is due to the clinical activity they generate.

During recessionary times when so many families are struggling, and all too often failing, to make ends meet, it is understandable that there will be scrutiny of and resentment at those who continue to have high incomes. Hospital specialists are such a group. As I mentioned, Ireland (very foolishly in my opinion) elected many years ago to follow the British model of specialist practice, one in which a tiny number of consultants supervise the activities of a large number of juniors. At the same time the dominance of middle-class cultural attitudes means that around 50 per cent of our population elects to have private insurance.

Small number of doctors + plenty of customers = distorted market = big private incomes. Note to minister -- if you find this offensive appoint more specialists. Note to society -- the way to deal with large incomes is through the taxation system. Note to consultants -- accept the new arrangements. They will make no difference to your working conditions.

Senator John Crown is a consultant oncologist

Sunday Independent

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