Dara Gantly examines what the HSE has in store for those consultants identified as having exceeded their specified private practice ratio
We were grateful to receive the media statement on the appointment of Eugene Murray, CEO of the Irish Hospice Foundation, as the new Chair of the Consultant Applications Advisory Committee (CAAC) in time for last week’s issue of Irish Medical Times. The former Head of Television Current Affairs and Director of Business Planning at RTÉ, and board member of St Luke’s Hospital, will bring a wealth of managerial experience to the CAAC — effectively a replacement for Comhairle na nOspidéal.
Importantly, as a former editor of the flagship TV current affairs programme, Today Tonight, he also fits the bill of ‘independent chair’, as prescribed in the new consultants’ contract (Appendix IX), unlike — in some people’s view — the man he replaces, Seán McGrath, HSE National Director of Human Resources. Previously, the HSE had believed McGrath was ‘sufficiently independent’ to do the job.
So, the consultants seem to have won this particular round, but the gloves may yet be taken off over the coming months — this time over the issue of consultants’ private practice.
The latest available Performance Report from the HSE for November 2009 includes consultant private practice activity during the period April to June, as reported through the HIPE/Casemix system. The summary report indicates the proportion of consultants by hospital who are compliant with their contractual limits under the consultant contract 2008. It also shows the proportion within 10 per cent of the contract ratio, as a guide to highlighting the most significant non-compliant areas. It makes for interesting reading.
Just six hospitals report 100 per cent compliance among their consultant body for both inpatients and day cases, five of which are in the Dublin Midlands region. They are: Tallaght; Naas; St Columcille’s, Loughlinstown; St Michael’s, Dun Laoghaire; and Bantry Hospital. One further hospital — Monaghan General — reported full compliance for inpatients, but just a 66.67 per cent observance rate for day cases.
This increased to 83.33 per cent of consultants at the hospital who were within 10 per cent of their contract ratio.
At St John’s Hospital in Limerick, none of the consultants were meeting their contractual ratio for inpatients, and just a fifth were within 10 per cent of their requirement.
Also in the Mid-West, Croom Orthopaedic Hospital reported 14.29 per cent and 21.43 per cent of its consultants meeting their ratios for inpatients and day cases respectively, compared with 75 per cent and 87.5 per cent in Ennis.
The percentage of consultants within their contract ratios for inpatients and day cases at some of the major academic teaching hospitals were: CUH – 50.96, 55.77; Mater — 75, 86; Beaumont —58.23, 78.48; UCHG — 49.23, 72.31; St Vincent’s — 83.33, 91; and St James’s — 74.73, 92.31.
The HSE is clear on what tomorrow is supposed to bring, with the process to deal with non-compliance, it says, already under way in those hospitals experiencing difficulties. Section 20 of the consultant contract provides that if the appropriate ratio is not achieved after the prescribed period, the consultant is required to remit private practice fees in excess of the ratio to a research and study fund under the control of the Clinic Director.
The implementation of the consultant contract has been included as a key performance indicator for 2010 by the HSE. Consultants have received an individualised report each month since the beginning of 2009, which outlines their individual private practice details. This report also goes to the Hospital Manager and Clinical Director.
How it works is that consultants who are exceeding their private practice ratio are supposed to engage with the Clinical Director and Hospital Manager to address this within a maximum of nine months. If after this process the appropriate ratio is not achieved, either the facilities for the excess private practice will be removed or the consultant is required to remit the private practice fees in respect of this activity to the hospital research and study fund.
Consultants are angry. They have yet to agree on the methodology of calculating these figures and believe the numbers are, in fact, hiding some fundamental flaws. Indeed, many of the figures are unaudited, although the HSE has indicated that a hospital-by-hospital audit is currently under way.
One major ‘flaw’ in the system, perhaps, is the fact that for the past seven months or so there has been as many as 900 public beds closed, which is going to distort any public-private ratio. The fear is this will only get worse in 2010 with further bed closures.
The IHCA also insists that the HIPE system was never designed to record such data, and fails to account for certain clinical activity in outpatient and emergency departments, and work carried out before a diagnosis is made and treatment initiated. The HSE, however, believes this information now provides the basis to follow up with individual consultants who are exceeding their specified private practice ratio.
Fines, perhaps. But, realistically, could facilities for private practice ever really be removed from consultants, given the extent to which public hospitals depend on income generated by private patients as an integral part of their budget? In an atmosphere where consultants are facing further cuts in salary in 2010, any attempt to recoup earnings from private practice may well prove unacceptable to the profession. But the HSE seems equally determined to push things through.
It is recognised that the use of data is transforming the management of our health service. Yet it is imperative to ensure that data is always as accurate and meaningful as possible.
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