There appears to be a strange convergence on both sides of the Irish Sea in terms of the much needed reforms of the respective health services of the UK and the Republic. And the long term reputations of two senior players may rest upon their success, Tony Blair and former Tanaiste, Mary Harney. On the face of it, Harney may prove the more adept at picking her fights.The Bagehot column in the Economist does not think that the signs of a successful outcome for the British PM is good:
In the first place, the practice-based commissioning that both leaders set such store by is in trouble. The primary care trusts, which do most commissioning now, are determined to hang on to what they see as the most interesting part of their job. For their part, GPs are reluctant to take on new responsibilities when they suspect the government is trying to think up ways of retrospectively cutting the over-generous earnings it foolishly bestowed on them.
Second, despite the spur of tight future spending constraints, it is highly doubtful whether either a Brown or a Cameron government will have the nerve to see through the closure of inefficient hospitals; but without that, even modest productivity gains will be impossible to achieve. The Tories’ campaign to “Stop Brown’s NHS cuts” is as cynical as it is shortsighted.
Third, there is the problem of the consultants, the NHS’s top doctors. As a recent series of television programmes—in which Gerry Robinson, a successful business troubleshooter, tried to fix the NHS—graphically demonstrated, the most important cadre of professionals in the health service is neither institutionally nor psychologically under the control of managers. That will barely change even if the market-led reforms are fully implemented. Sanctions will continue to bite hardest on managers who are largely powerless to change the working practices of professional staff.
But the Tanaiste, with a smaller target to hit and the explicit backing of Finance Minister Brian Cowen is preparing to take on the Consultants, who exercise major control over how the health service is delivered:
She is to bring a proposal to Cabinet in 10 days’ time seeking approval to advertise for new public hospital consultants.
“At the moment, there are approximately 2,100 consultants in Ireland. I want to see that number increase to 3,600,” she said. Under the proposals, consultants appointed under the new contract would receive salaries of up to €240,000. Informed sources said that there would be premium payments of between €60,000 and €80,000 above the current pay levels for consultants.
The Minister’s proposals will also include new measures aimed at ensuring existing private practice rules are strictly observed for consultants retaining the existing contract.
The intent is to break a log jam in the rapid development of the Republic’s Health Service infrastructure:
The Minister’s plan would involve an international advertising campaign initially to secure more than 200 consultants in a number of speciality areas. One type of contract would involve doctors being employed exclusively in the public services and paid a salary of up to €240,000. It is unclear whether this figure incorporates a potential bonus payment of up to 20 per cent also to be in the new contract.
A second type of contract would allow doctors to see fee-paying patients in the public hospital or in any co-located private hospitals established on the campus. The consultant with private practice rights would have a lower salary. They would not be eligible for the bonus scheme. The new contract would be offered to all 2,100 existing public hospital consultants in addition to the new employees.
It is though, as Stephen Coleman noted last Saturday a stratagem fraught with both huge risk, and serious pay off (subs needed):
Taking on powerful interest groups in open combat is certainly not the Taoiseach’s style and the timing is not exactly suitable for a political leader with his cautious approach.
Ms Harney, though, has picked the time for battle with her eyes wide open. The consultants’ contract has been a festering problem in the health service since Charles Haughey signed the deal in 1979. Any minister for health over the past two decades could have taken the stand that Ms Harney is now adopting, but none of them chose to do it because the consequences of defeat were too terrible to contemplate.
What Mary Harney is doing is comparable in political terms to what Margaret Thatcher did at the time of the miners’ strike. If she doesn’t win, the Government’s entire health strategy will be left in a shambles, the HSE will have its authority undermined and the PDs as a party – and the Government as an entity – will suffer a loss of credibility.
On the other hand, if she wins, one major reform of the health service in the interests of consumers can truly begin, because the stranglehold the consultants have had over any change will finally be broken. In political terms not only will the PDs win, but the entire Government will be able to bask in the reflected glory of having taken a decisive stand in the public interest.
Health has been viewed in the past as a poisoned chalice amongst FF insiders. When Ahern appointed Micheal Martin to the job, Leinster House was awash with speculation that it was in order to keep a potential internal rival occupied with apparently insoluble problems. And as we have seen, the government’s popularity is not such that any of the backbenchers will be overly tolerant of a rough ride, when it comes to facing down what is wider perceived as a highly privileged insider group.
Early indications suggest the Consultants are not going to roll over easily. Keep watching this space!