The Real Culture War in Healthcare

Culture War in Healthcare

Sunday Independent – 4th Feb 2007

The resumption of stalled contract negotiations between the Irish Hospital Consultants Association and the Health Service Executive is to be welcomed. There is uniform agreement that our ailing health service is in urgent need of increased resourcing, including a substantial increase in the ludicrously low numbers of specialists in our hospitals (per capita, the lowest in Europe). The clamour for increased consultant posts has generally been led by consultants themselves, with the block provided by the Department of Health, initially refusing new posts for financial reasons, and subsequently citing the need for contract reform.

The impasse concerning the issue of new consultant contracts has been portrayed by the national commentariat as a line-in-the-sand stand-off between reactionary self-interested doctors on the one hand, and the forces of the enlightenment (in the unlikely guise of Minister Harney and the Irish Civil Service) on the other. According to most editorialists, the consultants, while girding themselves in a spurious cloak of pseudo-public interest, are in fact desperately seeking to maintain those very work practices (particularly an allegedly unique-in-Europe public/private practice mix) which are the sole, proximate and material cause of waiting lists and other pathologies in our health service. The ministerial threat to respond to alleged consultant intransigence by marginalising the current cohort of senior doctors, instead appointing 1500 specialists to new public-only contracts, is being cheer-led by those who believe that the consultants, are the final untamed leg of the church/legal/medical vested-interest tripod.

This is not consistent with the facts. Specifically, as a public/private consultant, I would like to know exactly which part of my self-interest would be hurt by the appointment of 1500 new consultants, specialists who will decrease my public work-load while being largely prevented from competing with me in private practice. When I return home from a fairly typical 12 hour day, in which I generally have the very great and humbling privilege of interacting with more than 90 brave public and private cancer patients, these new appointments seem, from my selfish perspective, to be a fairly good idea. In fact, they seem like paradise to me (perhaps bettered only by having all of my spiritual and corporeal needs looked after for all eternity by 72 luscious HSE contract negotiators).

The actions of the IHCA, fairly uniquely for a trade union, have in fact tended to militate against the financial self-interest of existing consultants. Minister Harney offered an unbelievably sweet deal (smaller share of public work, no competition in private practice, the option of a taking the new contract with a 40 hour week, doubled public salary and higher pension). No, the objections of most consultants are in fact, rather more principled, and relate to the real agenda which is being pursued, namely that of control of the health service.

Let us first consider the potential impact of the current and proposed new contractual arrangements on waiting lists and service. It is scarcely credible that any informed commentator who has actually worked in one of the adult general hospitals where the waiting list and accident/emergency trolley crises bite hardest, could, in the absence of dense ideological blinkers, come to the conclusion that the current public/private mix is the principal cause of waiting lists. The appointment of 1500, or of 15,000 full-time public hospital consultants will not abrogate waiting lists in a system where surgery is frequently cancelled, not because the consultant has decamped to a private hospital, but because there are simply not enough beds, or because the theatre or the intensive care or the recovery room has been closed. Nor will one patient spend one day less on any trolley because the 1500 extra consultants are trying to perform conjuring feats with fixed, (or, all to often, decreased) numbers of in-patient beds.

No, we have waiting lists because the method we finance our hospitals incentivises waiting lists. A fixed sum of money is doled out to hospital administrators on January 1st of every year, with instructions that it has to last until midnight on December 31. If money is running short in November, wards are closed, and services curtailed. Remember, patients on waiting lists are free. Chemotherapy, surgery and intensive care cost money. My own hospital once took this philosophy to its logical conclusion by circulating referring family physicians with a request that they send their patients elsewhere. In what other field of human enterprise does a provider ask its customers to bring its business to a competitor? Does any reader remember the “Yes Minister” episode about the hospital with no patients?

Minister Harney has been a great disappointment to many advocates of health reform. This once radical challenger of the status quo, a woman whose courage in the face of political intimidation made her a hero to my generation, has tamely bought into long-established civil service policy, i.e. the development of a highly centralised, bureaucraticised British NHS-like system. Her only departure from the civil service wish list was to foster the parallel development of a necklace of private hospitals (rosary would probably be a better term, given their ownership profile) around the country. True radical reform, would have involved a degree of energy, leadership and commitment that Minister Harney can apparently no longer muster during these latter days of her political product life cycle.

The central problems of our health system are inequality, and incentivised inactivity. The Harney reforms will in fact, entrench both of these dysfunctions.

On the other hand, the introduction of universal, socially-based insurance, provided by a mixture of not-for-profits and traditional commercial companies, and redeemable by individual patients in a single tier hospital system, would have addressed both problems. It would have empowered patients, incentivised quality, efficiency and appropriate activity, and ended the odious, unfair, inequitable two-tiered public-private split.

Instead, we will have an apartheid-like health system. The privately insured will get care in a network of luxurious, inappropriately small, non-comprehensive, intensively profitable private hospitals, subsidized by tax breaks, built and owned in many cases by government supporters, and staffed by a cohort of senior specialists whose skills will no longer be available to “public” patients. Public patients will instead will find themselves in an under-resourced, hideously bureaucratized, over-regulated system where treatment decisions will be made not by highly trained clinicians, but by committee. Rest assured, few of its clients will be civil servants or PD politicians.

The real reason for medical hesitation to embrace the Harney reform process, is in my opinion, the perception that a medical culture war which began in the UK is spreading to Ireland. Eisenhower warned of the dangers of a military industrial complex. We now have an analogous situation in the UK and Irish health services, where a “hospital administrator/civil service complex (“HACS”) has taken firm control of hospital management. The HACS wish to remove the historical clinical leadership and advocacy roles from senior specialists, transforming us into technicians, who would implement therapies not on the basis of scientific evidence, but of bureaucratic approval. The HACS believe that they, and they alone amongst a mob of warring vested interests can provide sufficiently objective leadership to the system.

The situation is particularly acute in the UK, where one such bureaucracy, the hilariously named National Institute of Clinical Excellence, or NICE (Orwell anyone, remember the Ministry of Love?), has denied many life-saving, prolonging and enhancing therapies to patients, disproportionately to women with cancer. Their grounds for rejection, are cost. One of the few positives of our miserable health system in Ireland was our superior access to cancer drugs, probably reflecting the fact that our bureaucracy was less muscular than its British counterpart. They have learned fast, and already, a new equally hilariously named Irish NICE equivalent (NOICE anyone?) called the Interim Health Information and Quality Authority, has delayed the introduction of the best drug we have ever seen for kidney cancer, pending cost analysis.

Consultants are not blameless. A minority of my colleagues, motivated either by frustration with their public working conditions, or by greed, have abused the privilege which the public/private contract has given them. The tenor of the press coverage, and in particular the systematic assumption that we are all gougers, has nonetheless been hurtful and regrettable. Many (but not enough) doctors have stuck their necks out over the years in an attempt to improve the lot of public patients. Some have suffered substantial intimidation. Most have worked quietly away, seeing all patients referred to them regardless of method of payment, in primitive conditions, and without the support, esteem or encouragement of our bosses.

So what advice to my comrades in the IHCA? In the face of the new contracts and appointments, the only viable options are capitulation or the path of the kamikaze. When the collected power of Fianna Fail, Fine Gael, Labour, the Greens, the even greener Sinn Fein and the Irish Civil Service all agree on an issue of public policy, it will very likely be implemented, with or without our consent and participation. We cannot even hope for the happy release of a new government, given the abandonment by Labour of their innovative insurance plan. In the event that negotiations break down again, we should not refuse to cooperate with the government in implementing the new policy and progressing the new jobs. We should however insist that any new contracts grant cast-iron guarantees of whistle-blower protection, so that we can continue to advocate within and without the service, on behalf of our patients.

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