Analysis: Will hospital consultants' new-found militancy block future healthcare reform? Maev-Ann Wren reports
The flexing of industrial muscle by hospital consultants this week is an ugly affair - for consultants, for the Minister for Health, and most of all for patients.
The consultants appear motivated by fear, the Minister by financial probity; the patient is the victim. The issue of liability cover has already provoked industrial action by consultants in Australia. It seems inevitable that the legacy of this week's events will be a new climate of militancy among Irish consultants.
Having crossed the Rubicon of industrial action over the issue of clinical indemnity, will consultants again down tools over issues with more immediate relevance for patient care, such as public consultants' right to private practice? Or such as the Hanly Report's requirement for rostered team-working by consultants, with reduced delegation of care to junior doctors?
Hospital consultants have defeated Ministers for Health before. In 1974 Brendan Corish of the Labour Party abandoned his attempt to introduce free hospital care for all when faced by the threat of industrial action by consultants who would not accept salaried status. Then, as now, they threatened to withdraw all but emergency services. Corish postponed introduction of his scheme "to avoid any danger to human life".
When the Irish Hospital Consultants' Association was formed in 1988, its leader Prof John Fielding said it would never go on strike but would effect change through the reasonableness and strength of its arguments. Little over a year ago, the IHCA's secretary-general, Finbarr Fitzpatrick, restated this strike ban but predicted that "notwithstanding our lack of industrial muscle", the IHCA would defeat the minister's plans to restrict newly-appointed consultants to public work in their early years.
Last weekend, while he clung to the semantic fig leaf that the consultants' provision of emergency cover meant their action was not a "strike", Mr Fitzpatrick described mounting "militancy within the profession" and a rapid "sea change" among his members "that many people thought would take 10 years to come about".
"We are in a whole new world now. When you do it once, isn't it easier to do it again? The psychological barrier has been broken."
However, the consultants' militancy reflects a very specific fear which unites doctors, who might differ on a broader reform agenda. This unifying fear is of loss of cover for historic liability. Retired and employed consultants share a genuine and understandable concern about the consequences if the UK-based Medical Defence Union (MDU) will no longer cover them for the costs of compensating patients for what the courts deem their past errors or indeed for defending themselves even where no error is found. Will they face bankruptcy at the hands of an increasingly predatory legal profession? Consultants ask why, if the Minister wants to reduce the spiralling costs of liability insurance by having the State take over their insurance, will he not take over their past exposure for what may well have been public hospital care?
Micheal Martin probably did not anticipate a consultants' strike when he unilaterally introduced his enterprise liability scheme. The Minister apparently lost patience with the IHCA, which his Department regarded as having taken up the MDU's cause. The MDU had been flagging it might not cover the historic liabilities of Irish obstetricians. Never an insurance company, this mutual body had not charged enough in premiums to meet the rising cost of claims and might have a legal if not a moral basis to walk away from them.
The MDU apparently anticipated that the Government would follow the UK government in agreeing to cover its unknown historic liabilities in return for a fixed MDU contribution. Both Governments now regard that as having been a bad deal. The Australian government, in contrast, allowed its largest medical defence body to go into provisional liquidation before agreeing to bail it out, and later introduced a special levy on doctors to cover unfunded claims, provoking a wave of resignations from the public health system.
While some protagonists suspect Machiavellian intentions in the Department to "take on consultants" before substantive contract negotiations, others perceive a "mess", exacerbated by a trigger-happy response from the IHCA, which it may yet regret. In its late conversion to trade union tactics, the IHCA is operating outside traditional union disciplines, while the IMO - which also represents consultants - has been seeking a resolution of this dispute through the mechanisms of social partnership. Meanwhile, Mr Martin shows no intention of repeating Brendan Corish's climbdown and essentially wants the IHCA off the pitch so he can negotiate.
The minister has already given ground. The State will top up the liability cover of consultants engaged in wholly private practice, a significant new state subsidy to the private market for care. The State will doubtless also eventually pick up the tab for some proportion of consultants' historic liabilities, with the MDU covering the remainder.
When patients receive news of cancellation of their operations this week in public and private hospitals, the IHCA presumably wants them to reflect on the importance to their well-being of motivated and secure consultants. The general public might reach a further conclusion which is less palatable to the IHCA, that, as the true paymaster of both public and private consultants, the state should have the right to determine their conditions of employment in the impending contract negotiations.