The stand-off between consultant representative bodies and the HSE regarding public/private ratios shows no sign of being resolved. Paul Mulholland reports
In an interview with this paper, HSE Human Resources Director Mr Sean McGrath revealed that last winter the IHCA had promised to engage with the Executive on data used to verify the consultant public/private ratios, in exchange for the creation of additional Type B* and C contracts. The offer, however, was rejected by the HSE. And so the stand-off between the consultant representative bodies and the Executive continued on the issue, with no immediate sign of resolution. Data continues to show consultants are often significantly in excess of the agreed private ratio. To date, no money has been paid into the research and development fund by consultants who are deemed to have carried out excessive private work, as unions are adamant that the system used to measure the ratio is flawed. However, the HSE says that both the IHCA and the IMO agreed to the system during negotiations of the 2008 contract. How did this situation come about? And are there any moves to resolve the issue once and for all three years after the contract was signed?
Background
In the Consultant Contract 2008, it was proposed that for the measurement of consultants’ public and private activity, the HIPE data on day cases and inpatients would be adjusted for casemix using parameters estimated by the National Casemix Programme. The contract was intended to make the split between a consultant’s public and private work more straightforward and measurable, in comparison to the previous contract. A letter from Assistant National Director, Human Resources, Consultant Contract Implementation, Mr Barry O’Brien, on July 31 2008, stated: “A key measure of the success of Consultant Contract 2008 will be the extent to which we can assure those receiving our services that they will be treated – at a minimum – in line with required ratio.” Under the contract the private practice limit for new consultants is 20 per cent.
The contract also makes provision for limits up to 30 per cent for consultants who had existing contracts of employment that permitted levels of private practice in excess of 20 per cent. When consultants were in breach of the private ratio, they were to be issued with written warnings. If the matter was not resolved, they were required to pay money into a research and development fund, which was to be administered by a clinical director.
Emerging difficulties
The Comptroller and Auditor General Mr John Buckley spoke at the Public Accounts Committee (PAC) in November 2009 about his annual report for the previous year. In relation to public/private practice, Mr Buckley said that when his report was finalised in September 2009 arrangements had not yet been embedded to monitor the extent of private practice carried out by consultants. In response, then HSE CEO Professor Brendan Drumm told the Committee that the measurement system for public/private activity has been rolled out to the 49 acute hospitals. He said the creation of the system was a “huge undertaking,” but that measuring processes had been agreed, and that consultants were now provided with monthly reports about their public/private work.
However, Mr Buckley’s report for 2009 also found problems regarding public/ private mix. He found significant reporting delays of up to nine months after private work was performed by consultants. Also, private practice levels in many hospitals continued to exceed permitted levels, in some cases significantly so. The proportion of consultants in breach of their private ratio was of the order of 33 per cent, according to the report. By mid-August 2009, 35 consultants with private practice in excess of the authorised limits had received letters from the HSE seeking remittance of their excess private practice income. However, none of this money had been paid, according to the HSE.
One of the main reasons for the nonpayment of fees was the opposition of unions to the measurement system. The IHCA wrote a response to the Comptroller’s report on September 30 2010. The Association had previously sent a submission to the PAC in March stating that the HIPE was inadequate in capturing the caseloads of consultants. In its letter to the Comptroller, the Association stated that the system ignores all of the work required to arrive at a diagnosis and was therefore unreliable. Also, none of the activity in intensive care units is captured, while very little, if any, of the clinical activity of consultant radiologists, consultant anaesthetists, and consultant pathologists is captured by the HIPE system.
The IHCA said it had many examples of inaccurate data captured by the system. A consultant radiologist was deemed to have a ratio of 53 per cent private for inpatients and 100 per cent private for day case activity. Upon review he discovered that this was based on a reported total clinical workload of just nine cases over a three month period, even though he had conducted several thousand examinations in that time. Also, the Association stated that it had examples of consultants on a Type A contract, which only allows for private work, being reported as having treated private patients. The IHCA noted that a PA Consulting report in 2007, which was commissioned by the HSE, estimated that it would take three years to develop an appropriate system and that would necessarily be more comprehensive than the HIPE system. Also, it pointed out that the joint working group established in 2008 to develop a measurement system had not completed its work. “It is therefore premature to claim that the system has been fully developed,” the IHCA stated.
Current situation
In May 2010, 226 consultants were written to regarding non-compliance with their private practice contractual limits. None of these consultants have yet paid into the research and development fund, even though they had been given nine months to do so. Recent data from Healthstat shows that the majority of hospitals are exceeding the private ratio. For instance, figures between February and April 2011 show that only 35 per cent of consultants in the Mid Western Regional Hospital, Limerick were in compliance. However, serious concerns continue to be expressed about the measurement system. Recently retired consultant geriatrician Professor Cillian Twomey told IMN that monthly reports he received showed private clinical activity, even though he had not treated any private patients in that time. Meetings between unions and the HSE on the issue are continuing. The HSE has accepted in numerous meetings with the IHCA that its public private measurement system does not capture all a consultant’s public patient clinical activity, Secretary General of the Association, Mr Martin Varley, told IMN.
He said that at a meeting with the HSE on May 26, the Executive agreed to address concerns about the measurement of consultants’ clinical activity. However, in his interview with IMN, Mr McGrath said both parties had signed up to the verification system during the contract negotiations and they had to work from there, though he added the HSE was cognisant of the data limitations of the HIPEand casemix systems in relation to smaller specialties and caseloads of some doctors. He added that in recognising the representative bodies’ issues with the verification process, the HSE was currently focusing on those consultants who are over 50 per cent in breach of their ratio and will then work downwards. At the moment, however, there appears to be little hope for agreement on the issue.
