There are now six hospital consultants in the North Eastern Health Board (NEHB) area with question marks over their clinical practice. Is this health board area unique in this respect or are its problems similar to the rest, except they have become public?

It was revealed this week the work of a further two consultant obstetricians in the NEHB area, as well as Dr Michael Neary in Drogheda, was being examined. A fourth hospital consultant has had his work examined in an outside review for allegedly keeping patients in hospital longer than necessary. It is understood the doctor refused to participate in the review, and does not recognise the findings, which called for a management review of his work.

The Royal College of Surgeons is investigating a fifth consultant after an external examination of his cases, including two in which patients died. The external inquiry concluded that "one of the deaths need not have happened" and that the other followed poor decision making. The report was written by a consultant based in Britain and was commissioned by the NEHB. This surgeon was investigated on two previous occasions by other surgeons working in the Republic, and their recommendations fell short of placing restrictions on his practice. He is now on paid leave and is understood to be co-operating with the RCSI review, due to be completed shortly. A colleague of this surgeon took early retirement in 1997 after he too was investigated by a committee appointed by the health board following a complaint from a patient's family.

The NEHB area has up to 50 consultants and has had its share of problems, which are undoubtedly experienced in other health board areas, but the public has simply not been made aware of them. Chief among the reasons is the lack of clinical audit. The Medical Council recently proposed that doctors should be certified as competent every five years. "It is no longer acceptable for bad doctors to be identified and sanctioned following an incident. Our responsibility as a self-regulating profession must be to do our utmost to ensure that patients do not come to harm in the first place," it said in a discussion paper submitted to the Minister for Health.

But is this enough? Clinical audit would allow a transparent system where it would be possible to see how doctors perform and highlight discrepancies between the results of one hospital and another.

The Minister for Health, Mr Cowen, said earlier this year he would like to see league tables which would allow the public to assess the standard of medical care in individual hospitals within five years. If doctors, he said, wished to continue to have a self-regulating profession, their actions would have to become more transparent and accountable, without any "hidden medicine". The present system is far from providing such a situation.

The Department of Health is involved in quality improvement schemes in various hospitals and a system of accreditation has been introduced for the seven major acute hospitals in the State. However, Department sources admit clinical audit on a formal basis "is not as widespread as the Department would like it to be".

The other reason for these problems is the contract under which consultants are employed, known as the "common contract".

The contract has been described as cumbersome and convoluted and weighted in favour of the hospital consultant in these matters. "It is broad and imprecise and presumes a level of participation that is not binding," said one legal source. "It presumes things will be done without giving the power of compulsion to ensure they are done. When there is conflict and the employer goes looking to the contract to see how it may be addressed, they cannot get an answer. It implies that the consultant will assist in solving the problems."

According to Department of Health sources, during the last contract negotiations in 1997 there was a mentality on the consultants' side of "what we have we hold" in terms of alterations to the provisions covering disciplinary action. It must be asked, though, why the Department did not make more effort in this regard, rather than simply throwing up its hands.

Of course there is a far different perspective from the consultants' side. It is argued that while a difficult situation existed in the past, changes made in recent years have made the system more workable. They blame complexities in the document on the employers.

It could be argued that the NEHB, with its six consultants under examination, is weeding out and dealing with its problems. There is a strong feeling among many involved with the health services that other health boards may have stood back from taking action because they do not feel confident that the consultants' common contract would back them up.

The most recent disciplinary changes negotiated in 1997 have not been tested in the courts. Under the existing terms of the contract, it may be some time before we see the first case.