From top: Secretary general of the Irish Hospital Consultants’ Association Martin Valey, Fianna Fáil TD John McGuinness
In the Dáil, at a meeting of the Special Committee on Covid-19 Response…
The committee heard that the State had “no plan B” when it made a deal with private hospitals in March, to increase capacity and lower the burden on public hospitals in the event of an extremely steep surge of Covid-19 patients.
The steep surge envisaged did not occur and the deal, which saw the State taking over private hospitals for €115million a month, will finish at the end of June.
The plan also included private-only consultants being offered a HSE public patient-only contract and, the committee heard, 291 private-only consultants out of 550 took up this contract.
And the Dáil heard that the treatment of up to one million patients may have been delayed as a consequence of the deal.
At the outset of the meeting, Secretary General of the Irish Hospital Consultants Association Martin Varley said:
“The test of time has confirmed that the private hospital agreement, which is costing approximately €115 million per month, represents poor value for money from patient care and taxpayer perspectives.
“The experience is that of very low private hospital bed capacity occupancy, at approximately one third on average, and low utilisation of theatre and other ancillary facilities. Furthermore, the private hospital contract is prohibiting the provision of urgent care required by patients with non-Covid illnesses. This is leading to the accumulation on waiting lists of a large number of patients who require urgent care.
“There is now the additional risk that these patients will deteriorate clinically and will increasingly evolve into emergency cases if they are not treated without delay.”
Consultant at Tallaght Hospital and IMO representative Dr Anthony O’Connor told the committee:
“We started with 700,000 people on the waiting lists for hospital care. By the time we get back to work, we will be dealing with at least six months’ pent-up demand and less capacity to deal with it than ever before.
“We have heard a great deal about patients being locked out of care in recent weeks, but what has not been stressed enough is that public patients have been completely locked out of care and are likely to remain so for the foreseeable future.”
…We have been told for the past three months that we are in it together and to hold firm. We cannot continue to lock public patients out of the service any longer. We need a good and robust plan for how we are going to get public outpatient and inpatient services up and running.
Dr O’Connor agreed with Sinn Féin TD Louise O’Reilly that such a plan should include using the private hospitals that the State is paying for until the deal runs out at the end of the month.
Mr Varley also told the committee:
“The primary lesson I have learned from this particular exercise is that we need engagement on a tripartite basis. We need engagement with health service management, the private hospital associations and the private practice consultants.
“It is difficult actually to design the most effective way to do something if one does not engage with all three in a round-table setting. That was the big failure. Looking back on it, we can see why and the rush that did not happen.
“However, as we go forward, it is hugely important that there is tripartite engagement to optimise the use of our capacity in our public and in our private hospitals.”
Mr Varley also had this exchange about indemnity with Fine Gael TD Jennifer Carroll MacNeill:
Martin Varley: “We need to be always available to provide surge capacity if there is a second wave. Indeed, we must optimise thereafter in order that we do not have the capacity to be underutilised as we have experienced over the past two months.”
Jennifer Carroll MacNeill: “That was for several different reasons, however. That was not just about a contract or otherwise. That was about the rate of presentations as well as everything else.”
Varley: “Yes. There is always a danger it will continue because inflexibility in contracts and arrangements can actually be the devil in the detail.
“We have observed that with our whole-time private practice consultants, who are more than willing to look after Covid and non-Covid patients. In fact, a large number of them actually did so on a pro bono basis until the bank holiday weekend in May when the provision for clinical indemnity for them in that respect was removed. That was extremely surprising for consultants who wanted to look after patients.”
Carroll MacNeill: “That was clarified fairly quickly, however.”
Varley: “It took a week or two to reverse it. We have never really found out why it happened. It was quite bizarre in the extreme.”
Mr Varley also had this exchange with Fianna Fáil TD John McGuinness about a ban, since lifted, on private hospitals from testing for potential cancers submitted by consultant who had not signed a Type A public patient-only contract:
John McGuinness: Last week, I asked a question about the various samples that were taken and we were told that if someone did not sign the contract A documents, samples would not be processed. What was the fallout from that?”
Martin Varley: “The fallout was very significant. It put consultants in an invidious position. If a consultant was providing care to his or her patients and could not sign the contract because rooms facilities were not provided for, he or she found that the consultant pathologist in a particular laboratory to whom samples were sent in good faith was being told the specimens could not be reported on. We could have been talking about cancer specimens. It left both sets of consultants in an extremely difficult position. It got rectified after a week or so but we had similar circumstances, as I said, with pro bono—–”
McGuinness: “How many patients were affected by that decision?”
Varley: “Unfortunately, I do not have that detail but there could be a significant number, allowing for the fact that approximately half of the private practice consultants had not signed a contract. I am not in a position to guesstimate but it could be significant.”
McGuinness: “Who issued that instruction?”
Varley: “To my understanding, the instructions in relation to indemnity cover by the State and the State Claims Agency were being issued by the State Claims Agency on the advices of the health service management. It was, therefore, a joint effort to provide the cover for indemnity. I do not know who exactly took the decision. Obviously, the State Claims Agency issued it but I expect it did so after consultation.”
McGuinness: “Consultation with whom?”
Varley: “It would have to be the health service management. That would include, in my view, the departmental officials, HSE officials and, potentially, individuals at ministerial level.
McGuinness: “In reaching an agreement regarding the private hospitals, did the Department of Health or HSE take into consideration the debt that was being serviced arising from consultants investing in the services they were delivering? Was that question ever dealt with in the context of these negotiations?”
Varley: “We had raised it quite early on in the discussions; I would say in or around the early days in April when it became clear to us that the type of contract being offered was type A only. If a less costly contract had been offered, the cost of rooms would not have been an issue.
“However, when it became quite clear nothing was going to be offered other than type A, we raised the issue of rooms costs. We put it to the health service management that certain specific cost headings should be agreed as being eligible.
“We did not get definitive agreement even on specific cost headings. Following on from that, we got commitments that further engagement, involving the national director of finance and an independent accountancy firm, would arise to work on that on the following Monday. I have had no communications in the interim despite seeking engagement to agree the broad headings. Even today, I am not aware of any private practice consultant who has signed the contract who has had his or her significant rooms outpatient costs covered.”
McGuinness: “Does Mr Varley believe that is an issue that has to be addressed? Is it an outstanding issue as far as consultants are concerned? Will they approach the HSE or the Department to find a resolution and compensation?”
Varley: “It is an issue on which we have had some commitments, which will be addressed. However, the detail has never been progressed, to the extent that, following a meeting with the Minister and his senior officials in the first week in May, we sought such commitments and a number of our consultants emailed their costs in a very transparent manner to the senior officials in the Department to ask them to confirm if these costs are eligible, and they have not had any response in the affirmative or otherwise.
“The general response has been that the CEOs of the private hospitals should now address these issues but I am led to believe that the CEOs of private hospitals are encountering similar difficulties to those that we have encountered in trying to get agreement on even the cost headings and the particular costs.”
McGuinness: “With regard to cancellations of procedures or ongoing treatment and care of patients, what does the waiting list look like now? How many were cancelled? How many are likely to now form a new queue to receive the care that they were getting from a private consultant?”
Varley: “It is difficult to estimate. Two or three things are happening at the same time. Some consultants would have seen their patients on a pro bono basis in their rooms but could not refer them and guarantee continuity of care. There is an aspect of care not being followed through. There is no doubt also about the aspect that some outpatient clinics could not continue in the uncertain environment that exists vis-à-vis covering costs and keeping clinics going at the normal rate. I am not on the front line so unfortunately I do not have all that detail.”
McGuinness: “Has Mr Varley any idea about cancellations? Is there a way to establish the number of cancellations across the hospitals?”
Varley: “There is but one would have to survey consultants individually. I was trying to guesstimate the total number of outpatient clinics where outpatients would be seen in private practice consultants’ rooms. Even if one allowed for 33 patients to be seen in a week across two clinics, in two half days, there could be in excess of 1 million very quickly. I am guesstimating that 20,000 outpatient clinics would normally take place in a week but it could be a lot higher. I do not know how many of those are lost.
McGuinness: “Some consultants have complained to members of the committee that in the context of that new arrangement, where private hospitals were taken in charge by the HSE, the output was very low because there was no working arrangement. Instead of covering a number of patients, as with the figures Mr Varley has just given us, they were not able to do that number. As a result, there was little value for money.”
Varley: “Yes. There were other contributory factors. For example, we sought a lot of clarity about indemnity. Clinical indemnity is multifactorial and multidimensional. A private practice consultant has clinical indemnity for outpatient consulting rooms and for the private hospital. It is only in the last week or two that we have had absolute clarity that a private practice consultant who has signed the contract is also indemnified for treating public patients in his or her outpatient clinic.
“As I referred to earlier, many variables were not discussed or provided for. We flagged those quite early. The frustration that private practice consultants had was that we were not getting answers, decisions or practical approaches.”
McGuinness: “As many as 1 million patients suffered from this.”
Varley: “This is the real problem. Many patients have suffered and care has unfortunately been delayed.”