Hospital consultants are often accused of serving their own interests over those of their patients - particularly public patients. Is this a fair analysis, or are they simply being scapegoated for problems within the system? EithneDonnellan, Health Correspondent, reports.
Depending on who you talk to, hospital consultants are variously described as arrogant and distant, impossible to arrange to see, and only interested in making money from private practice, or they are portrayed as hard-working, dedicated professionals who are visiting patients on their wards at all hours of the day and night. Regardless of which category all or most of them fall into, they are collectively coming under fire in report after report as being at the root of many of the ills in the public health service.
This week they were blamed for significantly contributing to overcrowding in accident and emergency departments. CAPITA, an independent team of consultants engaged by health service employers and nursing unions to look at the issue, accused hospital consultants of not doing ward rounds often enough, of doing ward rounds too late in the day for patients to be discharged, and of holding patients in beds over the weekends to keep those beds for their own "mostly private" patients on Mondays.
The consultants' main representative body, the Irish Hospital Consultants Association, says holding onto beds just doesn't happen. However, the independent team from CAPITA who visited 23 hospitals across the State weren't the only ones to find evidence of it. Sheila O'Connor of the patient advocacy group Patient Focus says she has personal experience of it.
"I know personally of somebody who was brought into one of the major Dublin hospitals for a trivial procedure on a Friday night even though she wasn't to be operated on until Monday. Her consultant had booked the bed for her for the whole weekend. She went in on Friday night, went home on Saturday for the day, returned to her hospital bed on Saturday night, went home on Sunday for the day, was back in the hospital bed on Sunday night and underwent a small gynaecological procedure on Monday. It was like B&B. It's crazy," she says.
"The girl was a bit narked about it herself because she knew there were others waiting for beds in casualty at the same time," she adds. Unsurprisingly the patient in question was on private healthcare.
Consultants working in the public system are, however, under their contracts, perfectly entitled to treat private patients in public hospitals. For this they get paid extra by the VHI or BUPA, on top of a minimum salary of between €120,000 and €140,000.
Some 20 per cent of beds in public hospitals are officially designated for private use, but many suspect up to 30 per cent at any one time are occupied by private patients. While there is no clear evidence that this is the case, it wouldn't be unexpected given that almost half the population is now covered by private health insurance.
Furthermore, it is often claimed that consultants working in the public sector, who are obliged to work at least 33 hours a week and give 80 per cent of that time to public patients, do not always live up to this commitment.
"This public impression is fanned often by hospital management," the general secretary of the Irish Hospital Consultants Association Finbarr Fitzpatrick claims.
"If consultants aren't fulfilling their duties why is action not taken against them by hospital management? If this is happening hospitals are culpable for not taking action," he says.
Dr Orla Hardiman, a consultant neurologist at Dublin's Beaumont Hospital, feels sure there are some consultants not fulfilling their obligations to public patients but says she doesn't know too many of them. Most consultants, she insists, work way beyond their 33-hour contractual commitment.
Giving an example of an average working week, she says she is always at work by 9 a.m. and two evenings a week doesn't get home until after 8 p.m. Apart from doing four public clinics a week and one half day's private practice, she has two formal ward rounds per week, is on call one week out of three, is responsible for teaching medical students, supervising research projects, and attending to administrative duties. Many weekends are also taken up attending meetings and conferences. "I'm not unusual. Nearly everyone I know does academic and administrative work at night," she says.
She feels a few "bad apples" in the profession have caused all consultants to be tarred with the one brush. In addition the fact that they are well paid and are seeking a 10 per cent pay hike makes them easy targets for criticism when there are problems in the health sector, she believes.
Nonetheless, she points out that consultants are the ones with whom the buck stops and the ones who are sued if something goes wrong so they deserve to be well paid for the amount of responsibility resting on their shoulders.
Regardless of how powerful a group consultants are and how fearful nurses and others may be of challenging them, it is inevitable they will have to begin to adapt to different work practices in the near future. The national health strategy, published in late 2001, set as one of its goals agreement on a revised contract for hospital consultants to provide "greater equity for public patients" by the end of 2002. Negotiations on this haven't started yet, however.
A plethora of other reports have also recommended changes in their contracts, including the Deloitte & Touche value for money audit of the health system, also published in 2001, and the Brennan report, which was outlined in The Irish Times this week, to be published next month. It wants, among other things, to see active monitoring of their work commitment to public patients.
There are 1,550 consultants in the State, 1,400 of them working in the public sector and 150 of them exclusively in private practice. Some 600 work in both the public and private sectors. They are mainly men aged over 40 and Fitzpatrick claims, on average, they suffer more ill health and are likely to die younger than members of other professions. He points out that it is as stressful for a consultant to walk out of his outpatients clinic and find 60 patients staring at him, all wondering when they are going to be seen, as it is for the patients who are waiting. He accepts the amount of time the consultant will be able to see each patient for is unsatisfactorily short and points out that in some instances he/she will only be able to see the most acutely ill. "This creates pressure, anxiety and tension both for patients and consultants."
He stresses there are more than two million outpatient attendances annually, 1.25 million A&E attendances and almost one million in-patient stays. With so few hospital consultants, it is inevitable, he says, that not all patients will see a consultant. "People often say you see the nurses but you never see a consultant, it's because there are so few of them."
This also limits the number of ward rounds they can do and the times they can do them at, he claims.
"We are often at the receiving end of complaints that are not of our making. A consultant can see a patient who needs a hip operation and tell the patient he will probably not be seen for two years. The consultant is then blamed for the delay.
"The lack of access to treatment within a medically acceptable timeframe is the cause of major aggravation among patients and it's all too frequently directed at consultants and they are not the ones who decide the number of beds in a hospital."
Furthermore, he acknowledges mothers often express concern that, despite being private patients, their consultant doesn't turn up when they are having their baby. "A consultant can't give a 100 per cent guarantee when a woman comes to him/her for a scan at three months, that he will be there in six months at 4 a.m. when her baby is being delivered. The reality is that there were more than 54,000 births in the country last year and there are less than 100 obstetricians. A consultant could be dealing with a difficult birth and may not be able to go to a run-of-the-mill one going on at the same time," Fitzpatrick says.
This may sound reasonable but it's not just this which aggravates patients. Sheila O'Connor of Patient Focus believes many consultants still have an attitude problem as portrayed by several witnesses to the Lindsay tribunal, which inquired into the infection of haemophiliacs in the State with HIV and hepatitis C from contaminated blood products. The former director of the National Haemophilia Treatment Centre, Prof Ian Temperley, came in for particular criticism from former patients and their families, but the tribunal, in its final report, published last summer, said it did "not believe he is or was arrogant, cold or dismissive".
The Irish Patients Association chairman Stephen McMahon says nonetheless that consultants' communications skills often leave a lot to be desired.
"We find far too frequently that some consultants - while they may be brilliant or close to the gods - they do leave a lot to be desired when it comes to their communication skills. This is apparent from the way that they deal with their patient when they break bad news, or when they fail to give adequate and direct answers to families when a death has occurred," he says.
Dr Moosajee Bhamjee, a consultant psychiatrist and former TD who is based in Clare, agrees consultants often lack proper communication skills. "We have bad training in communications. We are all trained to look at an illness rather than seeing the person who is ill," he says.
"The newer consultants are different to the older ones. They are much easier to address and they spend more time with the patients and they see them as a whole person," he says.
Consultants in general, he adds, are used as scapegoats when people look for someone to blame for the crisis in the health care system. "The whole system needs shaking up, not just one section of it. I think we all need to look at where we all can make changes."
Dr Hardiman is also in favour of change. She agrees consultants should be made accountable for their budgets, as recommended in the Brennan report. "It's very easy to spend money when it's not yours to spend but we would probably be more efficient if we had to be more accountable."