Your Wealth is your Health

Having recently reviewed my annual subscription for private health insurance, I considered reducing my level of cover in an effort to reduce the cost. However, having watched the second programme in the 3-part series Surgeons I’ve decided against making any changes. Our Minister for Health is determined to implement new changes in the Consultants’ contract of employment, to meet the needs of our health service. Has anyone ever heard her mention the needs of the patient? Her continuing plans to reform the health service by encouraging privatisation, makes private health insurance cover seem all the more important. And that’s exactly what the Department of Health wants!

The programme featured the work of two neurosurgeons, Donncha O’Brien and Ciarán Bolger in Beaumont Hospital. It was riveting stuff offering a unique insight into the lives of the doctors and patients featured whilst at the same time revealing the workings of a public hospital. Ciarán Bolger certainly doesn’t mince his words about the public health service. “The system is shite!” he says.

The HSE aims to employ 1,500 new consultants many of whom will be limited by the new consultant’s contract, to working in public practice only. There will also be strict monitoring of private practice. At the moment, public patients gain because they have access to the top specialists but this could soon become the preserve of private patients if the HSE continues to dictate to the consultants. Ciarán Bolger believes that a lot of the consultants will vote with their feet and go into the private sector so that we’ll end-up with an exacerbation of the 2-tier system. He believes that many of the existing highly trained consultants presently working in the public health service but who are also running a limited private practice, will opt to work fully in private practice. He says “WW3 would break out if nurses were told they couldn’t do agency work, or teachers couldn’t give grinds, or Gardaí couldn’t do bouncer work for night clubs”. He considers the new consultants’ contracts to mean that “you’re signing over a profession to be controlled by an organisation that can’t organise anything at the moment.” He says that it doesn’t matter how many consultants the HSE employ as it’s not going to make any difference if they don’t have places to work. “We need more beds, more resources, more surgeons, less administrators, and less people telling us how to do our job.” The proliferation in the development of private hospitals around the country at the same time as services in our public hospitals are being cutback, is no coincidence. Private health insurance is rapidly becoming a must.

The title of this post is a hard pill to swallow. It’s particularly offensive to those who cannot afford to ‘buy’ their healthcare. Our government wants to privatise healthcare in Ireland at the expense of the public health service. They want to scare as many people as possible into taking out private health insurance so that they can relinquish their duty of care. Healthcare in this country, is fast becoming a lottery. If you’re not in (insured), you can’t win!

This week’s ‘Surgeons’ programme, the final week in the series, looks at two revolutionary and radical surgeries being performed on children: cochlear implant surgery and limb-lengthening surgery. If the rest of the series is anything to go by, it promises to be excellent.

Thursday June 5th on RTE 1 @ 10.15pm

17 Responses to Your Wealth is your Health

  1. Grannymar says:

    Steph

    Two words hit me between the eyes ‘less administrators’.

    Since the health services in Ireland AND in the UK were put in the hands of administrators everything has gone downhill.

  2. What’s Grannymar doing with a watering can?

    😯

  3. Steph says:

    Grannymar’s trying to make her money grow, Paddy…

    so she can buy herself that bike! 😉

  4. Baino says:

    Steph I’m not adverse to the idea of a two tier system for those who can afford because this leaves places and speeds up the care of those who can’t it but it’s a crying shame that doctors don’t want to practise in the public system because the private system is so lucrative. NSW Health has recently announced new ‘incentives’ to attract doctors back into the public system . . we’ll see The problem with a country as big as ours is also getting doctors into the rural and outback areas. Private health simply doesn’t mean as much out there they just can’t get the services that are provided in the cities even if they’re prepared to pay.

  5. Steph says:

    Hi! Baino

    I’m not adverse to a 2-tier system either but not when it’s at the expense of the public system. Private healthcare for those who can afford it, is all very fine and dandy for elective surgery and routine illness. However, when you have a complicated medical history like I do, you often don’t have any choice in the matter. I have to go to where the most up-to-date expertise can be found and this is usually in the large (public) teaching hospitals. These hospitals are being run into the ground by cutbacks and the dictatorship of the HSE, forcing many of the highly skilled staff to leave the country/seek work in the private system. This is what Ciarán Bolger was referring to in the programme.

    Another thing that really bugs me is the way that healthcare has been made so ridiculously complicated. Instead of treating the majority of people under the one system, we have a choice of public beds/private beds… public waiting lists/private waiting lists… doctors in public practice only/private practice only and… doctors with a restricted private/public practice. Would it not be much simpler to have a universal system of healthcare serving the majority of people where the sickest get treated first, and reserve a smaller private system for those who can afford to pay big bucks?

  6. Ellie says:

    Does anyone know where the Bitter Pill has gone?? that was an outstanding blog and it has just disappeared! hope nothing bad happened to that doc who wrote it! read a very appropriate quote recently….
    “During times of universal deceit, telling the truth becomes a revolutionary act.” — George Orwell

  7. Steph says:

    Hi again! Ellie

    Long time no hear.

    Funny you should ask about the Bitter Pill as I went looking for it just the other day and was likewise concerned. It makes all that Dr X used to say about the medical profession, appear horribly true. I hope the decision to remove the blog was his alone!

    Sadly, yesterday I also found evidence of another excellent blog under threat of being pulled in the UK. Have a look at Mousethinks on my blogroll. It’s fantastic stuff, written by an A&E charge nurse but ‘Mousie’ is concerned she’s been outed.

    BTW I like your quote – very applicable to Irish health service!

  8. Knipex says:

    Sorry Steph but the consultant contracts are actually designed to limit their private practice.

    The current consultant contracts allows consultants to do private work using public facilities. In theory it limits private practice to 20% of their work but due to the way the contract was written its impossible to enforce. It also severely limits the availability of consultants out of core hours. (The contract only required Consultants to be on site during limited hours and outside of that you have to wait unless one come in). it also allowed consultants to bump private patients for outpatient and diagnostic visits using public facilities.

    Under the new contracts Consultants have to provide longer hours of cover, have to work weekends and can no longer bump patients for outpatient and diagnostics visits. If its public equipment then they all go on the same waiting list.

    There are three new contracts.

    A public only contact which carries a very generous (by international standards) salary.

    A public private contract (with an enforced 20% maximum private patients) with a smaller salary and the limits mentioned above.

    Then there is a private only contract which Ciarán Bolger mentions. At the moment there are already private only contracts so its not new. Bonn Secuors recruits its own consultants and always has (although as far as I know they do share come with the HSE under the old public \ private contract). This was necessary as under the new public or public private contracts no new consultants could work across there hospitals. (the only exception being where private and public hospitals are side by side such as James’s and Beaumount).

    It also significantly changes work practices to make consultants more flexible and to work in a team with nurses and junior doctors which they currently do not do.

    There are massive benefits from all of this to the public patients and the consultant fought tooth and nail for 5 years to resist this contract as it put limits on their private practice and the use of public facilities for treating private patients.

    The argument about loosing out on consultants to private hospitals is a non entity. private hospitals in Ireland are generally small hospitals with limited facilities, a small number of patients and limited beds. To base them selves in there hospitals would be career suicide for any consultant who wants to do research or advance themselves.

    While I don’t doubt the integrity of Ciarán Bolger you have to remember that he has a vested interest in this and the program was recorded while the consultants were in dispute with the HSE.

    As you know Steph I am no fan of the HSE but these contracts are the most significant improvement we have seen in the public health sector in decades is not ever. It will result in more focused patient oriented care public patients, will ensure that private patients are not prioritised for use of public equipment and that consultants spend more time with public patients.

    In this (if nothing else) the HSE and Mary Harney deserve to be commended. It took years but we are finally starting to see the overhaul of the health sector and the end of restrictive work practices.

  9. Knipex says:

    I just re read my post above and I didn’t make myself clear.

    While private only contacts have always existed they are not effected by the new contracts (how can the HSE set employment contracts for private hospitals) the new type C contract allows limited private practice outside of the site of public hospitals. This will allow the likes of bon secours to make use of public consultants on a private basis as they currently do.

    These contracts will only be awarded on exceptional circumstances and will be monitored. The criteria for awarding these contracts has been set and it must involve significant benefit to the public health system.

    All existing consultants with off site private practice will be allowed to continue but within the constraints of the public private contract.

  10. Steph says:

    Thanks! Knipex

    You needn’t worry – I’m well aware of the different types of consultants’ contract and the reasons why each has been drafted. I agree – they do pave the way for significant change with a consultant-led service 7 days a week. Incidentally, the IMO is still balloting it’s members on the new contracts and I think the outcome was due to be known today (June 3rd). It’ll be interesting to see if they follow the IHCA and accept the deal.

    My concern is not so much about these contracts but more about the consultants who reject them. If what Ciarán Bolger says is true, then the public hospitals may well face a brain drain if many of our most highly trained professionals opt to leave the public sector. It’s already happened with our nurses and NCHD’s who are leaving the country in droves/being attracted over to the private sector.

    Are you aware of the huge number of private hospitals that have sprung up around the country recently? Places like Mount Carmel and the Bons Secours are ‘old rope’ by comparison and are having to pull up their socks to compete with the new big boys. My worry would be that many of our more highly skilled surgeons will opt to consult/operate in these new fancy private clinics, leaving the public sector devoid of the top expertise.

    I agree – the hospital consultants have been playing games with the HSE for years as they don’t want their lucrative careers interfered with but I also know that there are many who deserve every cent they earn, for the huge workloads they carry. They are the ones I would be concerned will jump ship.

    Thanks for contributing to the debate, Knipex. I really welcome your contribution.

  11. Knipex says:

    I agree steph and have no problem with the level of remuneration received by consultants.

    You have always had and will always have a certain percentage of consultants working only in the private sector and I would not be worried about this increasing to too great a level. If they didn’t do it here there are plenty of opportunities in the UK, Europe or the US.

    Financially the consultants in the Public Sector are well looked after because for a change the HSE took into account the requirement to entice highly qualified people from abroad. Even the public only contract is well paid and allows consultants a significant amount of free time.

    To put it into perspective. Before agreement had been reached (although the outline was well known) the HSE advertised for consultants.

    At the time the consultant organisation and the doctor organisations were advising doctors not to apply, there was no contract to see, no pay levels agreed and yet they still received more applications than they had expected including a number of consultants from abroad.

    I would not worry.

  12. Steph says:

    Knipex – I see in today’s papers that the IMO have voted to accept the new HSE consultants’ contracts. There are a few remaining concerns to be ironed out but otherwise it does look as if come September 1st, Harney will have scored a winner. At long last!

  13. Ciaran Bolger says:

    I have been reading the above opinions with interest, particularly as they refer to my comments on the Surgeons programme.
    I am particularly frustrated by opinions shuch as those expressed by Knipex, as they reflect the general “percieved wisdom” and the much quoted HSE propoganda that Consultants interests lie solely in the arena of monetary compensation. While monetary considerations are not unimportant, they do not represent the major concern for most consultants. My major concerns are as follows:

    1. Currently my only concern is my patients welfare. Full stop, that is my primary responsibility. Under the new contract my primary responsibility is to the corporate entity of the HSE. Thus I have now an obligation to work under HSE policys, whatever they may be, including cost cutting of treatment etc.

    2. My role as an independant advocate for patients is removed. I would be unable to make the comments I made on the TV, without first clearing them with my ‘line manager’. Two guesses for the responce I would get to such a request.

    3. The idea that Consultants are only available for limited parts of the day or weekends is complete nonsence, and can be easily demonstrated as such. In my own practice there are 6 neurosurgeons. We cover the entire country (outside of Cork) 24 hours a day 365 days a year. Can any of you come up with a work schedule that allows this on the basis of the much publisised 33 hour working week?. The fact is that the vast majority of consultants work far in excess of their contracted 33 hour week, including out of hours and weekends. At the moment most of us do so out of a misguided sence of vocation. Not anymore. I supect that with the advent of the new contract, as the department of health discovered in the UK, the goodwill factor will dissapear. There will be a need to more than triple the consultant numbers just to cover the existing work schedules, never mind talk of service expansion.

    4. If their was a genuine understanding that consultant private work was interfering with the public hospital system, then the HSE would have banned the type 1 consultant contract and insisted that we all moved to type 2. In other words they would have insisted that all private practice was performed off site. In fact they have done the opposite. They have now (with the new contract) ensured that consultants are OBLIGED to do ALL their private practice within the public system. They have not insisted on consultants reducing the NUMBER of private patients they treat within the public system, in fact they are keen for such numbers to expand, they are just reducing the PAYMENT for treating those patients, with the balance (above 20%) going into the hospital coffers.

    5. The issue of the 80/20 mix is an interesting one. The percieved wisdom here is that consultants, though only allowed to treat up to 20% of their patients in the public hospital as private, abuse the system and actually treat up to 50% of the patients as private patients. Again not as straight forward as it seems. I freely admit that 50% of my patients treated in the public hospital are private (I honestly dont know the breakdown) yet I only have one waiting list for public and private patients. I make no distinction. So how is this? The reason is quite simple, the service is so deficient that most of my patients end up comming as urgent or emergency cases. 50% of the population have private health insurance. So 50% of the people crashing their cars, having Brain tumours or brain haemorrhages are private. Big surprise 50% of the patients in my beds are private! Honestly it doesnt take a brain surgeon to work this out. It has nothing to do with me, or a preferential selection of private patients!”. The HSE also know this. That is why they are not limiting the NUMBER of private patients under the new contract, only the number of patients being PAID for. Limiting Consultants to “20%” will achieve nothing, because it will have no impact on patient demographics and that is what decides the hospital case mix.

    6. There is an assumption that what was meant as a ‘consultant’ under the old contract is the same as a ‘consultant’ under the new contract. Not so. The new breed of consultant is very much the ‘yellow pack’ version. Less training, discouraged from advanced training overseas etc. It was only at the last round of negotiations that the HSE even conceeded that the new consultants would have to be on the specialist register!. We could easily increase the number of ‘consultants’ just by calling any Doctor in the hospital ‘consultant’, that effectivly is what we are doing. You are right, any advertisement for ‘consultant’ will produce a raft of applications, but from whom? Fully trained, including overseas experience at international centres of excellence (the standard for appointing people, especially surgeons, under the old contract)experienced, state of the art? Idoubt it.

    7. There has been much discussion of the value of a consultant PROVIDED service (the new contract) as opposed to a consultant LED service (the old contract). It has been accepted (without any debate I might add) that this is a good thing. Not so. If all services eg surgery, are only provided by consultants, then where do the next generation of consultants come from?. I tried to show on the surgeons programme the importance of the apprentice aspect of surgical training, by bringing a Non Consultant Hospital Doctor through an operation. It is essential that these doctors gain first hand experience of surgery etc. Including operating on their own, unsupervised, when they have reached a certain level of competence. If I do all the operating myself where does that experience come from?. It is akin to saying everyone going into a bank deserves to be served by the bank manager, quite right, so lets just make all the staff bank managers!

    7. The new contract has nothing to do with consultant hours of work, their pay or even the public private mix. It has everything to do with control. Everything to do with making an independant, ethically guided profession into a dependant group of employees, whose ‘ethics’ will now be decided by the Minister of Health of the day, through the control of the Medical Council, as facilitated by the recent Medical Practitioners act.

    I could go on and on but my wife is already putting my dinner in the bin!. These are the real reasons why there is so much concern re the new contract, especially among surgeons. Physicians will still be able to do off site private clinics so it will have little effect on them. Money? not in my top 7 concerns at least!

  14. Steph says:

    Welcome! Ciarán

    I’m really chuffed to hear from you. I respect your point of view and thank you for taking the time out to respond in such detail.

    I take on board all of what you’ve had to say. I’ve no doubt your explanation of the facts will help to clarify any misconceptions. I thought the surgeons programme actually portrayed your point of view extremely well and was yet another excellent production from the ‘Mint’ team.

    I find your paragraph (5) on case-mix very interesting. It really shows up the tactics used by the HSE. As you say, you have only one waiting list and treat people according to urgency. Seeing your card index system (on the programme) with so many ‘life threatening’ cases awaiting admission, was a shocking indictment of the state of our health service. In reality, each one of those red cards represents a life that is being failed by our health service. I find it outrageous that you and your staff, are put in the position where you literally have to dice with people’s lives when choosing who to operate on next. It’s wrong and this programme did well to highlight it.

    Frankly, I have enormous respect for (almost) all of the surgeons I’ve come across in my lifetime. I’ve witnessed first hand the enormous pressure consultants are under in a health system that is in chaos. This is where a programme like ‘Surgeons’ serves it’s purpose well in that it offers an insight into the reality of hospital life for the patients and the doctors. I’d like to commend you for your part in the programme, both this year and last.

    Sorry to hear about your dinner! 😀

  15. Knipex says:

    Ciaran

    Firstly welcome and I am very interested in hearing your opinions on the consultant contracts. To date most of my knowledge has come from the press and speaking to a small number of consultants who would have limited patient interaction and non surgical so allot of your concerns would be new to me.

    Secondly I apologize if I gave the opinion that consultants were only interested in monetary reward. This is obviously not so. Even ignoring the patient concern there is huge emphasis placed by a large percentage of consultants on research which is of course to the long term benefit of the patient. A certain percentage will always be be in it for the money as in any job but they will be a minority.

    I have always said and repeated it above that I do not think that the remuneration package on offer for consultants is excessive.

    My main concern regarding the current system was the use of public equipment and facilities to treat private patients ahead of public.

    As an example. I have private health insurance. About 2 years ago I had a problem and my GP referred me to a consultant who made an appointment to have a colonoscopy. Within two weeks of seeing the GP I had met the consultant and had the procedure in a large public hospital.

    My wife’s sister does not have private insurance was was also required a colonoscopy. She saw the same consultant as a public patient and waited 6 months for the procedure in the same hospital using the same equipment.

    My case was not urgent (it was a case of being 110% sure and we even discussed the option of not doing it) and a delay would have made no difference to my treatment. My sister in law on the other hand was a more urgent case and her treatment could not be started until the results of the colonoscopy were known.

    It was the only time I felt guilty for having private health insurance.

    If as you say the new consultants contracts will result in the lowering of the standards of care we have come to expect from consultants then I would have concerns.

  16. Ciaran Bolger says:

    Hi, I am sorry to hear about your sister-in-law and hope all ends up well. While I have no knowledge of the particular circumstance regarding the consultant or hospital in which you were seen, let me explain how such a situation arises in general.
    If you come to me as a public patient for a routine investigation e.g an MRI scan, or just as easily a colonoscopy, I have one choice of where I get that investigation done, the public hospital. So 50% of the patients I see (on average, going by the population stats in regard to private health insurance) go on the public list for the public hospital. However if you have insurance (the other 50%) I can admit you to a whole host of hospitals, only one of which is the public hospital. So already you are ahead of the game. Now in the public hospital the budget is limited, so places are reserved on lists for MRI’s etc for private patients. This is not done by the consultants but by management, because during those periods the hospital can bill for the use of the machine (MRI or whatever), bringing money into the public hospital outside the budget from the HSE. So if you are a private patient you are competeing for slots with less than 50% of the population (the rest have had the test done in a private hospital) to start with, and even if you are referred to the public hospital you go on to a list with fewer people on it. This again has nothing to do with consultants deciding to do tests on a private patient before a public one, it is a matter of resources and basic maths, and is re-inforced by the need of the public hospital to get extra income from whatever resource (eg an MRI scanner) that it has. The whole system is at fault, but once again the powers that be explain it away by blaming consultants, who infact are powerless in this situation.

    Regards

  17. Knipex says:

    Ciaran

    You raise an interesting point. However the logic for this practice is suspect (Not doubting your argument but am questioning the logic of hospital management) the income last year to the HSE from insurance companies was (from memory) in the region of 80 million which does not even register in the overall budget for hospitals.

    They are making public patients wait for what in in effect pennies.

    What is your feeling on the co-located hospitals and the effect they will have on this issue ?

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