Hospital consultants have been identified in the Brennan Commission report as the key mechanism by which accountability could be improved in the hospital system.
The report says one of the core principles of health service reform is that accountability for the spending of reserves should rest with those who have the authority "to commit the expenditure".
The commission says clinical consultants, and their practices in individual clinical specialities, should be designated "as the primary unit of accountability in the acute hospital programme".
The commission, chaired by Prof Niamh Brennan, acknowledges the difficulties posed by the concept of clinical independence - the freedom of doctors to decide on the appropriate treatment for patients. "Clinical independence or autonomy appears to be the distinctive feature of general hospital services which has defeated the application of management accounting systems to hospital expenditure in the past."
Referring to the common contract under which all hospital consultants in the public service are appointed, the report suggests that although resource management is part of the consultant common contract, resource management responsibilities are not being uniformly discharged. It, therefore, recommends that "hospital budgets should derive from the budgets negotiated and agreed with individual consultants for agreed outputs".
In a potentially controversial move, the commission recommends that the secretary general of the Department of Health "should take immediate steps to agree the necessary amendments to the common contract".
It further suggests that these amendments set out consultants' duties in planning and controlling the resources allocated to them, and that consultants be accountable for these duties to the CEO or general manager of the hospital.
The commission also wants the consequences in the event of a breach of these responsibilities to be outlined in a new contract. "We believe that such a system would create opportunities for improving value for money within the health service without compromising clinical independence and outcomes."
And in a move likely to be fiercely resisted by the Irish Hospitals Consultants' Association and the Irish Medical Organisation, the commission recommends that "all new consultant appointments, covering new posts and the replacement of existing consultants, should be on the basis of contracting the consultants to work exclusively in the public sector".