Sunday, January 28, 2007

Going Nuclear on the Health Service

In August 1981, Air Traffic Controllers (ATCs) in the USA went on strike. As Federal employees, the strike was illegal and President Ronald Reagan gave them a 48-hour ultimatum to return to work or have their contracts terminated.

A large majority (about 11,000) of ATCs ignored the ultimatum and were summarily dismissed. The Government brought in military and retired ATCs to supplement the minority of ATCs who had remained/returned to work, augmented by supervisory staff with ATC experience.

Naturally there was some disruption to air travel in US airspace, but the country kept flying and the strike was effectively broken. Over the following couple of years, new ATCs were recruited and trained and the dismissed ATCs were never re-employed.

Which got me thinking about the current impasse with the Hospital Consultants and what effect the “nuclear option” would have on the Irish Health System.

What is the Nuclear Option?

The “nuclear option” would be to deliver an ultimatum to the existing consultants - accept the proposed contract changes for newly appointed consultants (which don’t affect the T&Cs for existing consultants!) and cooperate fully with it’s successful implementation, or face dismissal from the public health service payroll.

Any consultant who refuses to provide written acceptance of these terms is summarily dismissed. Consultants who take any form of industrial action in support of their dismissed colleagues are also summarily dismissed.

The HSE would quickly appoint a tranche of new consultants - chosen from the ranks of registrars/experienced hospital doctors - the existing “no. 2s” on each consultants team and recruitment in UK and elsewhere.* These new appointments will significantly outnumber the dismissed consultants, in line with policy to provide a consultant-delivered service.

Assuming that these junior medics are willing to accept their lucrative promotions (and some won’t - but you appoint as many as you can and identify other suitable candidates for fast-tracking), what are the likely outcomes for the Health Service?

Likely Outcomes:

1. An increased number of Hospital Consultants seeing public-only patients in public hospitals should help to quickly reduce waiting lists (when coupled with other necessary procedural changes in hospitals).

2. Strong and decisive action against the all-powerful consultants should ensure the easier compliance of other vested interest groups e.g. junior doctors, nurses etc in making the necessary changes to improve hospital productivity.

3. The loss of experience and skills will inevitably mean an increase in misdiagnosis and sub-optimal outcomes for a minority of patients, including death. BUT this will be offset by a reduction in the number of sub-optimal outcomes, including death, for people who currently spend months, even years, on existing waiting lists. An actuarial exercise would be required to assess this equation, which would also be impacted by items 4, 5 & 6 below.

4. The dismissed consultants would not be redundant but would find themselves involuntarily redeployed into the private sector. Most would concentrate on private practice, greatly increasing the capacity in the private sector and this would probably lead to accelerated investment in private hospitals. With over 50% of the population holding private health insurance (e.g. VHI, BUPA, Vivas) demand for their services would be unlikely to diminish, at least in the short/medium term. This situation should somewhat ameliorate the risk of increased mortality in the public health system caused by misdiagnosis or loss of surgical skills.

5. The huge increase in the number of private consultants should, in theory at least, lead to more price competition and cheaper service. In turn, this should reduce the rate of medical inflation currently suffered by VHI and other medical insurance subscribers.

6. The National Treatment Purchase Fund would still buy surgical procedures from private consultants where the need arises. In addition, the fund could now buy consultancy and diagnostic services for complex cases where this was deemed appropriate. It could be the best of both worlds - still having access to the best medical knowledge/skills, without having to employ it on a full-time basis and pay the exorbitant salary and pension costs.

* SIMON P. KELLY, Consultant Ophthalmic Surgeon, Bolton Hospitals NHS Trust, confirmed on Morning Ireland (31.1.07) that the c. €250k pa salary on offer compared very favourably to consultants salaries in the NHS. He also pointed out that NHS consultants were able to earn productivity bonuses to boost their basic salary.

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