One of the major steps to implementation of Sláintecare is a new contract for hospital consultants which the Government has indicated it will move ahead with despite not yet having the agreement of the doctors’ organisations.
This contract includes an extended 80-hour week public hospital contract, with a salary of €250,000, and entitlement to private practice outside of the public hospital site, provided that the public commitment is complete. It is important to note that nothing in the Sláintecare proposals prohibits private healthcare, nor does the proposed consultant contract prohibit private practice.
While I have no concerns with the general principles of Sláintecare or the new consultant contract, this contract will create significant unintended consequences for maternity services.
If, for example, a patient needs to see a cardiologist or surgeon or neurologist with this new system, they will still have the choice to see that doctor in either a public or a private hospital, as long as the private setting is outside of the public hospital location.
This is in keeping with the principles of Sláintecare, as choice still exists. It is also responsive to the 40 per cent of the population who choose to pay for private medical insurance. However, uniquely, patients wishing to see an obstetrician will be prevented from seeing that doctor in any location outside of the public hospital setting.
This is because, while there are many private hospitals in which to see cardiologists, surgeons or neurologists (for example), there are no private obstetric hospitals in Ireland. Nor will there be any private obstetric hospitals in the foreseeable future because maternity services are effectively commercially uninsurable, outside of the public hospital system.
This anomaly exists in Ireland because of our complex medico-legal system, which is overly adversarial, expensive and designed to encourage litigation, with maternity litigation being by far the most costly.
The vast quantum of medico-legal settlements in obstetrics, and the challenges of agreeing life-long care costs for babies that may not actually have been injured at birth, means that it is impossible to obtain external insurance for this one specialty.
These unique challenges with insuring maternity services in Ireland mean that obstetric care will only exist in the public hospital system, because only the State can manage such future potential financial liabilities.
This is not the fault of maternity patients, nor is it the fault of obstetricians, yet it is maternity patients who will uniquely be deprived of the choice of opting for public or private healthcare with the new consultant contract.
Care pathways
This proposed contract will inevitably reduce choice for patients, and will result in the 40 per cent of maternity patients who have private medical insurance being told that they cannot choose a particular obstetrician for their pregnancy.
Many of these patients are not wealthy, but instead make personal decisions to forgo other expenditure so they can afford private medical insurance and make personal choices about their medical care.
They should not be vilified in this regard, but instead their choice should be respected. Just because many patients get superb care in the public service, this does not mean that other patients should be prohibited from following a different care pathway, in particular if they have personal preferences for how they wish to deliver.
One of my former roles as master of Europe’s busiest maternity hospital was the recruitment of new consultants.
We never aimed to recruit doctors with the bare minimum credentials, but instead appointed doctors with innovative new skills, typically learned from spending time training abroad, which has benefited the public health service.
When I tried to recruit such world-class doctors, I had to convince them to walk away from lucrative job offers in New York, Toronto or Melbourne, for example. A contract salary of €250,000 may be attractive in an Irish context, but will not be sufficient to lure these highly skilled and coveted doctors home from abroad, where they can earn multiples of this amount.
While other hospital managers will be able to offer the potential of supplemental private practice income when recruiting non-maternity consultants, maternity hospitals will not be able to make the same offer to potential consultant obstetricians. This contract will therefore greatly limit maternity hospitals’ recruitment opportunities.
We should ask, do we really want consultant obstetricians with the bare minimum credentials, or do we want to continue to recruit the very best, world-class, obstetricians to innovate and develop new services for the benefit of all patients?
It is important to point out that I personally am not impacted by this proposed contract and therefore I can speak honestly and without conflict of interest, as a former master seeking to recruit the best obstetricians for the benefit of all patients.
A voice needs to be given to the future generation of obstetricians in training, many of whom are watching the outcome of these consultant contract negotiations intensely.
Finally, can I offer a reasonable solution to avoid these unintended consequences for maternity services to the laudable goal of implementing Sláintecare?
Let us not get bogged down in dogma, rigidity and an insistence on a one-size-fits-all approach to healthcare design.
Proceed as planned with the proposed consultant contract, but recognise that maternity services are uniquely affected by the extreme Irish medico-legal environment.
Allow maternity hospitals to compromise by providing a private healthcare option for those patients who choose this care pathway. This will not undermine the overall goals of Sláintecare.
If real medico-legal reform occurs, and commercially viable private maternity hospitals are developed in the future, feel free to remove this exception.
But, until that time, allow maternity patients the exact same choices that Sláintecare already allows for other consumers of healthcare in Ireland – no more, no less.
Otherwise, if we allow this change in maternity services to sneak in unchallenged, we will be sleep walking into yet another example of healthcare for the women of Ireland that will be inferior to that of men.
Fergal Malone is a former master of the Rotunda Hospital Dublin