Doctors' pay - time to end the gravy train

Feb 23, 2011

Niall Hunter, Editor

Niall Hunter, Editor





The election campaign has thrown up a plethora of claims and counter-claims between the political parties about what is wrong with our health system and the best way to fix it.

The average punter at this stage must be bamboozled by the rain forest of manifestos and policy documents and angered by the rationalisations of the outgoing Government that, when it comes to health service reform, has confused spin with reality.

Thankfully, sometimes a salient point emerges that tends to put things into perspective if you are looking for a thumbnail sketch about what is wrong with our health system and what needs to be changed.

Two figures are relevant here. Firstly - €136,000. That's the amount a (presumably exhausted) junior hospital doctor earned last year in overtime payments alone. That's on top of his or her normal salary of around €60,000.

Secondly - €201 million. That's the amount you and me handed over to the HSE last year in overtime payments for junior hospital doctors. With 4,700 juniors working in hospitals, this works out at an average overtime payout of €43,000.

There would be wide variations in overtime levels between different junior doctors in different specialties, but some can earn six-figure sums in overtime alone, albeit for working well in excess of 70 hours per week.

This €201 million payout, the HSE tells us, was after recent (obviously limited) reductions in junior hospital doctor hours under EU law and following recent contractual changes which cut back on overtime pay.

I'd hate to know, you might say, what it was before these reforms. Well here it is - the total payout in junior hospital doctor overtime was actually nearly €250 million in 2008.

There are issues here that will need to be addressed urgently by the next Government. An obvious one is how safe can it can be for either patient or doctor to have medics working such long hours. The health authorities obviously don't regard this as too urgent an issue, as they presided over such a dodgy system for years when it was an easy option for them.

The second is, why are there such long working hours for juniors?

Some senior consultant trainers will still claim that junior doctors need the long hours in order to be trained properly. In other words: "I did 100 hours week and look at me, so why can't they do it?" This contention is hotly contested by many.

But, and here is the real crux - this type of health and safety Russian roulette in our hospital system was supposed to have been sorted out some time ago. We are still having the same debates today about what is wrong in the hospital service that we were having in the 70s, 80s and 90s.

We have been told for many years past that the old system of juniors, supposedly trainees, doing excessive amounts of service work, leading to huge levels of overtime, was going to end.

Also, we were told the system would be changed so that consultants would deliver, rather than direct , the service on the ground to ensure more senior doctor decision-making for public patients.

We had the Government-sponsored Hanly report nearly 10 years ago, which promised that in order to give us consultant-provided care, consultant numbers would double from around 2,000 to nearly 4,000 and junior doctor numbers would be halved, with less reliance on costly overtime.

We were told that an expensive and long drawn-out consultant contract review process would provide for more flexible consultant working and equal access for public and private patients to hospital care, and would facilitate consultant-provided care in public hospitals.

We were sold a pup.

Consultant numbers were not doubled. The HSE said last week only 500 additional consultants have been appointed to the system since 2005 and during that time, junior doctor numbers have only been reduced by a few hundred.

Mary Harney threw millions at consultants to get them to accept a new deal. Among the benefits of the new contract promoted by the former Minister was that it would allow for equal access for public and private patients to hospital diagnostics.

Waiting lists for diagnostics and outpatients at some hospitals stills stretch from months into years. Attempts to remove the distinction between public and private patients on these lists is meaningless when there is still poor access to care.

Nearly everyone on public hospital waiting lists, whether for diagnostics, an outpatient appointment or inpatient care, is a public patient. Private patients are not gloing to languish on a public list if they can pay for quicker care elsewhere.

The 'perverse incentive' system , whereby private medicine will thrive as long as public care is inferior in terms of access, is continuing.

Also, the new consultant contract has yet to implement an effective system that will control excessive levels of private practice in public hospitals by a minority of consultants.

All these inequities in our healthcare system may or may not be sorted out by universal health insurance plans from a Fine Gael/Labour Government. They may even say, after March 9, that "the financial situation is worse then we thought" and then long-finger their reform plans.

However, doing nothing is not an option, as Mary Harney used to say, usually before she did something that didn't change anything very miuch.

But if the next Government does nothing else it will be thanked by many for finally tackling the sometimes excessive earnings of doctors.

James Reilly's promise that the days of consultants earning €180,000 or more in public pay and a further €300,000 or more in private practice pay will end when it is in Government will strike a chord with people who might not necessarily be rabid blueshirts.

Many would also feel the good doctor could also do something too about a system that allows hospital doctors who are effectively trainees, although admittedly they are unfairly lumped with too much service work, to be paid six-figure sums.

You do not need to be seething lefty Provo to believe that such a system is wrong, especially in the current economic meltdown.

It should go without saying, but it often doesn't, that our medical personnel are of a high standard and work very hard. A cynic would say this should be axiomatic given the amount they are paid, which is higher than the rates in most other developed countries.

But that's probably being a bit too cynical. Medicine is a tough job deserving a fair rate for the work done - it's a question of what Government and society should determine to be a fair rate.

And like many others, doctors have had pay cuts recently. But then again, everything is relative. A newly-redundant construction worker about to emigrate will shed few tears for a professional having his or her six figure income cut by 10% - 15%.

To be fair to the medical community, it has not shown the same untrammelled economy-damaging avarice that continued among members of some other professions even after the recession set in.

However, most reasonable people nowadays would agree that a consultant getting paid €500,000 or more for public and private work is unjustified, a 26-year old trainee GP getting €80,000 a year is unjustified; a hospital trainee potentialy earning more than his consultant boss does from his public salary is also unjustified.

Surely such payouts are no longer sustainable in view of the state of our public finances and the rising costs of private insurance.

Questions must be asked too about the taxpayers' return on this investment. Surely we can get a better service, and a better system, without having to pay some people working in it quite so much.

You could argue too, in terms of moving to a more socially cohesive and equitable health service, with a proper sense of public ownership and staff buy-in, that we need a more level playing field in terms of earnings.

And excessive earnings for some doctors can potentially have detrimental effects too on manpower planning and unmet needs in healthcare.

Take, for example a doctor in his or her late 20s who has enjoyed a very generous salary while still in training. How enthusiastic is he or she going to be about the prospect of earning a more modest sum initially in, for example, an deprived inner-city general practice, or a rural hospital post with little opportunity for private practice, once they are fully qualified?

There is considerable anecdotal evidence that some senior GPs simply cannot meet the salary expectations of recenty-qualified GPs they might want to take on in their practices, so accustomed have some trainees become to high earnings.

Despite all the political promises, we have still not moved away from a health system that in many respects suits those working in it more than those using it.

The bottom line is that in order for the public to take true ownership of the health service it pays for, it is anomalous to have some within it earning the pay of high court judges, the Irish Taoiseach, the US President or even Irish bankers.

The country, the economy, society and the health service can no longer afford it.



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