True colours of the health service

IMO AGM Special: IMO CEO George McNeice tells Dara Gantly the HSE must recognise that the health service requires partnership not a ‘them and us’ approach to disputes

We all have our own vivid wish lists for the health services. More beds, less trolleys, additional white coats, but less red tape, faster transformation, but slower reconfiguration, and not before replacement services are in place. Your number one priority will no doubt be coloured by whether you’re working in primary care or a hospital setting, or indeed if you have to experience the health service firsthand as a patient, green with anxiety.
Economic crisis
The current economic crisis may have put pay to some of the more ‘lofty’ goals, but other aspirations are not as directly reliant on resources. While IMO CEO George McNeice agrees most developments in the health service over the coming years will be determined by the Government’s current fiscal position, a change in attitude on the part of the HSE/ Department of Health is of equal importance, and, in itself, costs nothing.
“If I wanted anything to happen within the next 12 months it would be that that relationship between the HSE, the Department of Health and the IMO in terms of how we are all involved in the transformation of the health service would change and actually work to everyone’s benefit,” he told Irish Medical Times.
“There seems to be an unwillingness, ‘culturally’, for the HSE to allow that to happen,” he added. “I suppose they have decided that if they engage with the IMO, the INMO or others, that the unions will be blocking them. We need to get over that attitude: it is both our jobs to implement transformation.”
Redeployment
Speaking to IMT before the conclusion of partnership talks between the public service unions and the Government over a possible new national agreement, McNeice said the transformation programme would be greatly helped if the issue of redeployment could be resolved. Being able to transfer the human resources from the hospital system into primary care would ‘significantly help’ general practice cope with the extra workload it is being asked to shoulder.
“If you are going to transfer a large range of services – be they blood testing, Warfarin, diagnostics, prevention or chronic disease management – to general practice, it has to be resourced. Presumably, if those services are already costing money in hospital, then those monies can be transferred across,” suggested McNeice.
But he believed the ‘policy decision’, in his view, taken by the HSE over the past four or five years to limit its contact with the unions has been one of the major ‘logjams’ impeding the transformation programme.
“They have tried to run the HSE as if they were running a private company that was non-unionised, which has caused a significant number of the problems,” he opined.
Adding that he hoped the new ‘national understanding’ would also deal with the whole issue of outsourcing, McNeice said the Executive needed to change its style and attitude in terms of how it deals with its trade union partners.
National understanding
“We need to get around a table – all of us – to discuss how things can be resolved. All of us have to accept that if there is a new national understanding we are bound by that. Equally, we have to understand what the current financial and fiscal position is, and what resources are available, and make the best use of those.”
General practice has been the hardest hit, perhaps, by this attitude of non-negotiation, he added, with June 2005 being the last time the GP contract was on the table for negotiation. It was agreed at the time that a comprehensive review of the GMS would be carried out, with all parties committed to “full and ongoing cooperation with change”.
A joint chairperson for what was described as a “fundamental review of the nature of service provision by GPs” was to be chosen, research was to be carried out, and a working group set up.
“If it had happened,” commented McNeice, “most of the problems that you now have would have been resolved; done and dusted. That was 2005. When was the HSE formed?” he asked rhetorically [it was January 2005]. “There is your explanation.”
He accused the HSE of trying to dismantle the ‘power’ of general practice and attempting to divide the specialty. “That has not worked for them. They are going to have to engage with general practice both locally and at national level through their representative organisation, which is us. The sooner they start getting around the table the better.”
GMS tenders
One of the best examples of this policy of division was the proposal in the McCarthy report to put GMS contracts out to tender. In its response to the An Bord Snip Nua, the IMO said the move would pit ‘GPs against GPs’ and doctors against medical corporations in ‘bidding wars’ for state contracts. Such a proposal would lead to the corporatisation of primary care and the dismantling of community general practice.
Commenting on McCarthy, the IMO Chief Executive said: “To think that somehow if you start contracting out to private companies the running of general practice that you are going to improve services that you already get is ridiculous. There is no place that I know of where this has been brought in and has actually worked. In fact, I believe the famous Darzi clinics in the UK [Lord Ara Darzi, the UK government appointed NHS Tsar] are losing so much money that the company now wants to pull out. So it just doesn’t work.”
Wider incentive scheme
In contrast, McNeice agrees with many of the findings of the recent Oireachtas report on primary care, which recommended that general practice should be owned and run by GPs, and that tax incentives should be used to build up the primary care infrastructure. Indeed, he believes there should be some form of a wider incentive scheme to that ensure a proper health infrastructure is in place before the reconfiguration programme closes down existing hospital services. And again, GPs should be involved on the ground.
“The HSE has to understand that you have to engage with organised general practice if you are going to have a sustainable system,” he elaborated, adding that using the excuse of the Competition Act – which is due to be amended later this year – just didn’t wash.
A good example of what can be achieved when both parties do sit down together, he said, was the recent provision to improve GMS access, which, contrary to what the HSE would say, was ‘proposed from this office’, said the CEO. “The IMO pushed it; the IMO insisted on the extension; and thankfully the Department of Health agreed.”
Consultant red herring
The culture within the HSE of reinterpreting the outcome of negotiations is also evident with the consultants’ contract, said McNeice – a contract that has never been fully implemented. Indeed, the current controversy over consultants’ public/private mix was in fact a ‘red herring’.
Firstly, he said it was clear that there was a ‘major problem’ with how the mix was being calculated, something that a functioning contract implementation committee could resolve. Secondly, the contract itself must be implemented fully on both sides, resulting in consultants giving up just the same pay reductions as everybody else – not more.
A ‘publicity stunt’
Talk of how the HSE was going to discipline consultants for not adhering to the stated ratios was also a ‘publicity stunt’ in the CEO’s eyes. “The fact of the matter is that we all know hospitals are starved of resources; there are reasons why more private patients are going through. In the majority of cases it has nothing to do with the consultant at all. The consultant treats the patient that comes in front of them.”
So what would be the reaction if financial penalties are initiated in May? “If you are going to take money off someone and you can’t stand over the evidence you have, presumably it will end up in court, which is not where I presume they want to end up,” warned McNeice.
“I don’t think anyone is arguing about the principal and about what is agreed on in the contract, but the HSE seems to be incapable of sitting down with people and discussing what to do. Are they saying that the ratio should remain, that the consultants simply won’t be paid, but the hospital will, so the public patients will continue to be disadvantaged?
Salary forfeit
“I thought all of this – according to the Minister – was about ensuring public patients had the same access. So what is the HSE doing about that? Here they are talking about how consultants are responsible for all this, whereas all they are proposing to do is take the money and make no extra provision for the patients who are on waiting lists. I thought the HSE was there to run the Irish ‘public’ health system,” posed McNeice.
In a broader context, he believes the HSE’s desire to publish information in the media that it thinks somehow embarrasses doctors about their income, amount of private practice, or overtime payments is not helping the Executive, but only alienating its own staff.
A ‘lost opportunity’
While he refused to place any particular blame for this on the shoulders of Prof Brendan Drumm [“I don’t like getting involved in personality issues”], the IMO CEO did feel there was a ‘lost opportunity’ over the past five years in terms of dealing with the medical profession.
“There was not a strong engagement with the IMO, particularly in relation to general practice. That was a lost opportunity. Other than that, I would wish Prof Drumm well. I will let history decide [on his achievements].”
Public health review
Developments in the field of public health medicine seem, on one level, to be more productive, with the independent review of the interim out-of-hours service, carried out by Scottish expert Dr Charles Saunders, expected to be available for this year’s agm. The IMO CEO is keen to start discussions on implementing the report and finalising the pay arrangements for a full-time service. He is also hoping to move along discussions with the Executive over how the new public health structures will fit in with the overall revised regional structures of the HSE.
Needs good will
What is more frustrating for him is the continued inflexibility of management over the upgrading of AMOs, which would have minimal financial implications. “It is my belief that this is an outstanding issue that needs good will from the Department, from the HSE and ourselves to resolve it. Fairness would dictate that it would be resolved,” he stated, adding that the issue may indeed end up with a third party for resolution.
But the whole role of community health doctors – a separate group from public doctors, he stressed – also needed to be reviewed. “I think community medical doctors have a huge role to play in the whole area of immunisations, child health etc… They are a group of doctors whose value has been presumed upon, and they have the capacity to expand and provide a very important service within the new health structure.”
‘Give and take’
As indicated on the front page of this supplement, the Chief Executive is pleased with the outcome of the new NCHD contract, believing it to be a good example of the ‘give and take’ that results from binding arbitration. He is also confident that the two outstanding issues – the 39-hour core week and the number of training hours per grade – will not prove too difficult to resolve.
“It is clear to me that the 39-hour week is either 39 hours nine to five or 39 hours five over seven. You don’t average your 39 hours; no other grade does. If there is to be a national pay agreement, that will talk about five over seven between 8am and 8pm. So the NCHDs will be no different to any other grade of staff,” he anticipated.
Membership rates in the IMO reached record levels last year, due entirely to the massive number of NCHDs who signed up with the union. Overall membership reached 7,505 — an increase of 1,332 (20 per cent) on the 2008 figure. As one would expect in a year dominated by new contract negotiations and High Court cases, the union saw its NCHD membership grow by a massive 1,431. However, membership in the three other specialty groups actually fell slightly: 29 fewer GPs, 77 fewer consultants and 20 fewer public health doctors were IMO members in 2009, when compared with the previous year.
Union relevance
The IMO CEO said it would be nice to keep as many of these new members as possible, but acknowledged that the NCHD figures do fluctuate from year to year, because of their transience. Indeed, membership retention and maintaining union relevance are the two key issues facing any union in the time of a recession. For what do you cut back on if your pay is cut? A lot of the times people will cut back on their union membership, acknowledged McNeice. “Sometimes unions are expected to be able to do everything,” added the CEO. “But our role is not to do everything. Perhaps we need to start managing our own members’ expectations in a better way now that we are in a recession.”
He believes that a lot of good work has been undertaken by the Irish Congress of Trade Unions (ICTU) over the past 12 months in terms of identifying exactly what the main challenges are and how the various unions can possibly pool their resources.
Social partnership
The question of whether ICTU should be involved in social partnership at all has also been discussed, added McNeice. “Perhaps ICTU got too involved in all of that and lost sight of the bread and butter issues of looking after its members. Perhaps you should have more of a buffer between you and the Government. All those things are being considered by Congress, and a lot of that will come to the fore this year. And a new agreement would help that.”
All of which brings us back to the issue of partnership and getting around the table to negotiate. The IMO CEO believes the decision taken by the HSE and the Department of Health not to engage with the organised medical profession has not helped anyone over the past number of years. “It certainly hasn’t helped the patient,” he stated.
“Branding doctors as greedy, as the Minister has done from time to time, also doesn’t help anybody because it simply is not true. It leaves resentment there for too long.”
Transformation plan
He accepts, however, that talk they must ultimately do if the transformation plan is ever to be implemented. “We have a job as trade union leaders to represent our members; to make sure their best interests are met. But the best interest of public servants, the public and the Government which pays for it are easily married. It is not as if they are three different things.
“Once a decision is made and is government policy, our role is to negotiate the implementation of that programme and to ensure that our members are properly represented. It is not our job to oppose it. So in relation to the transformation programme, the real issue is the HSE’s refusal to involve doctors in the process,” he concluded.
Despite all the colours of the health services, this is a black-and-white issue for George McNeice.