Analysis:This week's contract agreement marks the beginning of an important new phase in Irish healthcare, writes Dr Muiris Houston, Medical Correspondent.
The agreement of a new contract for hospital consultants, after four years of difficult negotiation, is most welcome. And while it is the end of a long and tortuous process, it marks the beginning of an important new phase in Irish healthcare.
Seen by many as a barrier to the transformation of the health system, the new contract will significantly alter clinical governance at the coalface of medicine. In particular, the introduction of clinical directorships and consultant teams should ensure a consultant-provided rather than consultant-led health service.
The reaction of existing consultants in different specialities and in different parts of the State to the new contract will vary.
Many of those working in hospitals outside Dublin and Cork will welcome both the formal extension of the working day and weekend rostering. It is common for senior doctors in hospitals such as Kilkenny, Wexford and Castlebar to work weekends in rotation, work that until now has not been recognised.
For some consultants in major teaching hospitals, with teams staffed by highly experienced senior registrars, being rostered for on-site weekend and evening work will represent a significant change in work practice. And the introduction of practice plans and clinical directorships could represent a significant culture shock for some.
There will effectively be five separate contracts available to consultants already in post: the two existing categories; the new type A contract for public-only practice; type B for those who opt to have an 80/20 split between public and private work; and type C, which will allow private practice outside public and co-located hospitals.
It is expected that most new appointees in psychiatry and geriatrics will be offered type A contracts - these specialists have little opportunity for private practice outside the main centres. Type B contracts are primarily designed to facilitate the co-location model. Minister for Health Mary Harney will be keen to see these offered to new appointees to co-located hospitals.
How many existing consultants will opt for the new contracts? It is difficult to predict; many in the profession say they will have to study the fine detail before deciding.
Surprisingly, perhaps, it is issues other than pay that may ultimately determine how many choose to stick with what they have. Consultants over the age of 60 may not wish to embrace significant change; how will they feel, after many years of independence, having to agree a practice plan? Others will be mindful of issues such as clinical autonomy and advocacy when making their minds up. For some, pension issues may be a deciding factor.
The appointment of the first clinical directors will be crucial to the success of the new arrangements. These senior doctors must retain the confidence of their consultant colleagues, while at the same time enforcing the cap on private practice, monitoring attendance and assessing adherence to practice plans.
As one might expect with a major deal like this, a number of caveats remain: the HSE annual service plan states that recruitment in 2008 must be within a national employment ceiling. This means that each new consultant post will be created at the expense of an existing non-consultant hospital doctor post.
Managing this transition will be a challenge. Keeping the recruitment budget-neutral may also be a challenge given the significant difference between new consultant pay rates and those of the junior doctors they replace.
A significant issue yet to be highlighted is the additional costs associated with new consultant appointments. Even without large teams of junior doctors, each new appointee will require additional resources such as secretarial back-up, outpatient facilities and procedure rooms.
Newly appointed surgeons will require operating theatre time, and rheumatologists cannot function fully without additional occupational therapists and other support staff.
But from a patient perspective this deal offers real hope. Logjams in specialities such as rheumatology and urology will be among the first to clear. Expect to see a significant number of psychiatrists appointed in early recruitment drives. And it is likely that posts needed to implement the national cancer-control plan, under Prof Tom Keane, will be the first to be advertised.