Tuesday 12 November 2019

Terence Cosgrave: Why our 'Gods' of medicine are wrong

The consultants who have just over €6,000 a week to live on will tell you that if their pay is cut, they will leave for some mystical better-paid land, but they won't, writes Terence Cosgrave

Somewhere out in the Amazon, or in central Africa there is a medicine man telling his people that they must sacrifice grain or meat in order to appease the Rain Gods.

A drought or a flood or some other calamity has brought it home to the tribe that they are not masters of their own world, but dependent on arbitrary outside forces which they can't predict.

Perhaps the medicine man's family has kept a record of the rains for many years and can predict an especially heavy rain season or drought.

However, he does it, he makes sure not to share the information, but use it to give himself divine powers of prediction -- the same old magic trick practised all over the world.

It's the old hook: "I know God. I chatted to God last night. God says you're to give me all your grain," and then the rain will return.

And it's practised everywhere, from Africa to the preachers of the Deep South of America -- give me your money or you're all going to die!

It's always the same old story for the magic boys.

But before we get tempted to take our missionary condescension to try to re-educate the naive Amazonian tribe, or even discuss the gullibility of Americans, remember, in Ireland, we have our own medicine men (and they nearly are all men).

They're called hospital consultants.

And they don't have to give you the 'I chatted to God line', because, in their world, they are God.

The junior doctors who aspire to their position don't want to cross them and neither do the hospital administrators.

The patients aren't likely to antagonise them, given that they hold the power of life and death over them.

It's why symphysiotomies continued to be carried out in Ireland when the rest of the world had judged them to be a brutal and unnecessary operation.

You just don't question the word of a consultant.

You and I might wonder why a person in such an important and highly-paid job has been clocking off for the weekend until now, not to be disturbed until Monday morning.

You'd especially wonder if the whole health service had had to do the same, because very little can happen in a hospital if the consultant isn't there.

It's like trying to have a Mass without the priest.

And every time a discussion arises on pay or conditions, the consultants have the best minds, the most money and the best PR to fight it, stall it, delay it and ultimately kill it with time and inertia. We'll see if that happens again this time.

You try to start the conversation with them: "You get paid a lot of money" and it ends up being a conversation about saving lives.

In the end, it's easier to take money from nurses, or junior doctors, and that's what mostly happens instead.

But, from a moral position, is it fair that the HSE should not be able to hire nurses because the money goes on consultants instead?

This is a zero-sum argument. There is only so much money.

And, of course, every time that argument is raised, the consultants hit back with the suggestion that if their wages are reduced, they would flee en masse to a mystical place where they can get even more money.

We'll come to that later. But for now, let's look at the last two years for which figures are available for the money made by consultants.

It's not enough to look at salaries -- that only gives half the picture. You need to look at their total incomes, including private practice. Thankfully, the Revenue Commissioners collect such data.

For 2009, they had 1,808 doctors making over €275,000.

In total, these 1,808 doctors made €849,545,623 in 2009 or an average €469,881 each. That's a very nice living.

But, of course, when the consultants' organisations hear that they counter with the "of course we're paying tax at an effective rate of 60 per cent" or some other such nonsense.

The amount of tax paid on this money in 2009 was €265,252,684 which made the effective tax rate for these lucky individuals 31.2 per cent.

So, effectively, these individuals took home an average of €323,170 a year -- or in other words had €6,214 a week to manage household bills and yachts in Marbella.

Could someone making that kind of money contribute more in an environment where, according to a recent survey by the Irish League of Credit Unions, over 1.6 million people in Ireland now have just €100 to spare at the end of each month?

But when you present information like that you will get hit with a million red herrings and excuses. You'll be told things have changed since then. But have they?

The following year, and the latest year for which the Revenue have full figures, shows that there were 1,770 doctors in the top bracket of pay and their income was €816,215,000.

That means there were 38 doctors who dropped out of the top tax bracket. But for the remaining doctors, the annual average income in this bracket was €461,138, which does indeed represent a drop of €8,742 in average income per year.

Effectively it means that they were only taking home €312,609 a year or €6,011 a week. Partly, that was due to an increased tax haul. They paid an average rate of 32.2 per cent in 2010, an increase in effective tax of 1 per cent.

That question is -- why are we as a society forking out these enormous sums to consultants when many of the rest of us are struggling to get by and the country as a whole is borrowing billions to pay such salaries?

Because the consultants will leave, as the cliche goes, "in droves".

And go where? To the UK, where a consultant starts at £74,504 (€93,074) and slowly rises to the highest threshold of £100,446 (€125,482)?

And that's even before considering Ireland's very generous pensions.

But you'll hear of America or Australia or some other mystical place where the medicine men will tell you they'd make much more and be more 'valued'.

I doubt it.

There, I said it.

I don't believe them.

The ultimate heresy which no-one in the system or outside will say to an Irish consultant. You. Are. Wrong.

In the first place, they are all by definition settled in Ireland. They are at least in middle age, have families and commitments, and they're unlikely to move all that readily, even if they could make similar money elsewhere.

Secondly, even if they do, there will be plenty to take their places at the generous rates we pay.

But then, (and here comes the clincher) they will say that the Minister for Health, HSE bureaucrats and other assorted bad guys like myself want patients to suffer.

That we don't understand the disruption that reducing their pay would cause as they scuttle out of the country to make more money elsewhere.

That we, not they, would cause untold misery to the sick by paying them less.

And in a way, of course, they're right. We just don't understand any of it because we are lesser beings.

We don't have their knowledge or their education (for which, incidentally we also paid vast sums) and we just don't see the damage we could cause to them, sorry, to patients, 'on the ground'.

And they would never do anything as damaging to their reputation as 'go on strike'.

Why would they when they have much more effective ways of putting a gun to the head of the health service by limiting service in other ways?

And now that the Minister for Health has negotiated a 'deal' with the consultants, it remains to be seen whether it will either work or be properly implemented.

The consultants' organisations rarely say 'No' to Government, but when they say 'Yes' they usually have another way of working the system so that their own goals -- pay and conditions -- are kept as high as possible without the peasants actually revolting.

The foot-dragging, delays, postponements and other stalling tactics will have to be countered with a proper enforceable deal, and if it is not, the minister is in a position to seriously reduce consultants' incomes after Croke Park expires -- or even sooner under the 'ability to pay' clause. That's if he should choose to take them on.

I mean, Minister Reilly has negotiated no pay cut for consultants, only future consultants. Let's get real. Prices for patients -- either public or private -- won't change very much. And the pay cuts for new consultants, well, that's all in the future.

A doctor told me once that his treatment of all patients always ended in failure. Sooner or later, they were all going to die, no matter what he did.

In the same way, the consultants can 'engage' in talks for eternity, because the status quo suits them so well.

Actually changing, actually agreeing and implementing change would only be of benefit to one group of people. Patients.

It's a pity the bookie shops don't take odds on who would win out in a struggle between patient benefits and consultants' pay and conditions.

We could all make a bit of 'big money' on that one.

Sunday Independent

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