Trust – between doctors and their patients, and between doctors and the HSE – is a word frequently used by Dr Gerard Crotty, the president of the Irish Hospital Consultants Association (IHCA).
It’s an emollient word, bathed in the kind of positivity beloved of politicians and public relations advisers. But what does it really mean when used by the leader of the country’s medical consultants, given their often fractious relationship with management in the health service?
The president of the IHCA is clear about one thing. “Trust doesn’t mean money.” Or, at least, it’s not “just” about pay.
“Some of the difficulties [with the HSE] are not about money, but we’re coming out of a difficult situation and there is a need for the restoration of normal working conditions.”
The association has a long list of pay grievances, notably the 30 per cent reduction in pay for new consultants imposed in 2012 and an earlier failure to honour promised pay rises in 2008. And whereas the other doctors' group, the Irish Medical Organisation, has remained in pay talks with the HSE and the Department of Health, the IHCA wasn't invited.
That’s because it isn’t signed up to the Haddington Road Agreement, maintaining it did not take part in any process of collective bargaining that could bind its members. So it hasn’t partaken in pay negotiations for at least three years and seems to have pinned its hopes on the potential of legal cases taken by individual members to effect a reversal of pay cuts.
Yet Crotty, whose two-year term of office began last October, insists the association is very keen to engage in serious talks. “We’d like to get back to the situation where we have agreed negotiated contracts that are honoured by both sides,” he says, in reference to the “unilateral” 30 per cent pay cut in 2012.
This, he points out, has resulted in serious problems with recruiting consultants: there are 300 vacant posts, and the agency bill has gone up by €70 million, far more than the amount saved. And while the IMO has negotiated the reinstatement of much of this cut, the IHCA isn’t happy that the top of the scale is still 8 per cent below what it used to be.
“We won’t accept we should pull up the ladder and say to our younger colleagues, ‘Actually, we agree you should be permanently paid less than us.’ At a time when hospitals are having greater difficulty recruiting consultants, we don’t think this is right.”
As for the bond of trust between doctors and patients, Crotty’s members are on the frontline in the health service, and well placed to report on its shortcomings.
“Patients are not getting the quality and timeliness of care they require, especially when waiting on trolleys or for appointments.” As many people are dying from poor care in emergency departments as on the roads each year, he says.
Extra resources
Unsurprisingly, given the large cuts in health spending in recent years, he sees extra resources, for staff and equipment, as providing part of the answer.
Consultants, he insists, have done all they can to remove logjams, and the day is long gone when well patients languish in hospitals over a weekend because no doctor is available to discharge them.
A consultant haematologist who works at Midland Regional Hospital in Tullamore, Co Offaly, Crotty is personally familiar with the issue of rising medical indemnity costs for doctors. It's a priority issue for the IHCA, which believes some of its members will be forced to give up private practice within months due to the rapidly escalating cost of premiums.
There is talk of changing court procedures and tort law, as well as greater use of mediation, with the aim of cutting the legal cost of handling medical negligence cases. This will take time, Crotty acknowledges, and short-term measures will be needed to deal with the crisis. These would see the State Claims Agency take on more of the burden of dealing with such claims.
Duty of candour
Crotty is supportive of Minister for Health Leo Varadkar’s plans to introduce a “duty of candour” for doctors in respect of their dealings with patients.
“Being open with patients reduces the risk of being sued. Very often, patients are looking for understanding or for an explanation. A lot comes down to the relationship with the doctor, and open exchange of information that respects autonomy of patients is equally important.”
Admission of error
However, there are reservations among medics. “In some people’s minds, there is a reluctance on the basis that open admission of an error, or something that could be construed as that, might be conceding liability or be used as evidence. So to make it fully effective it needs to be given some protection, in that disclosure made under duty of candour should be protected. It should not be used as evidence of culpability or liability.”
The handling of cases against doctors when things go wrong is something of a sore point within the profession. As Crotty points out, when a doctor ends up before the Medical Council, "the reporting of the allegations gets the headlines but when he's cleared, it's down the back of the paper, if it's reported at all".
“There may be a case for some cases that are not severe to be sorted out [with] a lower level of publicity,” he says.
A single mistake by a doctor doesn’t amount to poor performance, he maintains. “Poor performance is a pattern of behaviour. You’re not a poorly performing doctor if you make a slip on one occasion.”
The brain drain notwithstanding, Irish consultants are well paid by international standards; the annual OECD comparisons suggest their earnings are near the top. Maybe it feels different from the inside looking out, because discontent in the profession has, arguably, never been higher.
“There’s a huge problem with working conditions, in particular on-call. We have more women doctors now, and the younger generation want more of a work-life balance. They want a life outside medicine; they’re not prepared to devote their entire life to it.”
And while it is true that previous generations of doctors wrestled with the same workload challenges, “because we did it in the past doesn’t mean it was all right”.
“A tired doctor is not a good thing.”
