Health service reform proposals face industrial relations problems

A number of potentially explosive industrial relations flashpoints will have to be circumvented if proposals on reforming the Irish Health Service, published in October 2003, are to be implemented. This feature examines some of these problems, which include renegotiating the common employment contract of hospital consultants, and reducing the number, and working hours, of junior hospital doctors.

The long awaited report of a National Task Force on Medical Staffing, chaired by David Hanly, was published in October 2003, making a number of proposals for reforming the Irish health service. A number of formidable industrial relations hurdles will have to be cleared if the proposals are to be implemented; not least in relation to the requirement to reduce the working hours of junior doctors in order to comply with the relevant EU working time Directive.

Power relations

It is evident that, if the Hanly reforms are enacted - even partly - they are likely to impinge on existing power relations in the health service. In view of this, they could spark a number of industrial relations flashpoints, given the vested interests at stake, and the obvious temptation to utilise industrial and political muscle to shield those interests. The potential flashpoints, which are examined below, include: renegotiating the 'common contract' of hospital consultants; reducing the working hours and overtime of non-consultant hospital doctors (NCHDs); and the requirement to negotiate change with other healthcare workers.

According to the Hanly Task Force, 'a number of critical national recommendations, including measures to reduce NCHD working hours, should be implemented immediately throughout the country, with appropriate negotiation and consultation'. This reflects the requirement to comply with the terms of the relevant EU working time Directive (EU0005249F), under which the weekly hours worked by NCHDs/junior doctors must be reduced to an average of 58 by August 2004, 56 by August 2007, and 48 by August 2009. Thus, the Irish government, and health service management and unions, do not have much time in which to negotiate change before the first August 2004 deadline falls. Given the slow pace of change to date, it is difficult to envisage this happening.

In line with the Task Force’s view that the best option is to develop a team-based consultant-provided service, the report recommends a significant increase in the number of consultants, from the current 1,731 to over 3,600. Consultants would be expected to operate a far more 'hands-on' approach, and deal directly with the patient, rather than heading teams of junior doctors. This would also mean extending the working pattern from the current 33-hour/standard working week to cover evenings, weekends and, in some areas 24-hour cover, in an effort to provide a more 'customer-friendly' service.

In emphasising the requirement for a consultant-provided service, the report also recommends a significant reduction in the number of NCHDs, together with a reduction in their working hours. At present, there are over 3,900 NCHDs in Ireland, delivering 'frontline' services in more than 40 public acute hospitals and numerous health agencies. They work an average of 75 hours per week on site, encompassing significant overtime, and frequently longer, with some individuals working in excess of 120 hours. The recommendation that 'health professionals should work as part of a multi-disciplinary team, centred on delivering quality patient care over the full 24-hour period within an integrated network of hospitals', will not only affect the working patterns of consultants and NCHDs, who are represented by the Irish Medical Organisation (IMO) and the Irish Hospital Consultants Association (IHCA), but also on other healthcare workers represented by other unions. The report also examines the provision of acute hospital services, and the volume and type of services that each hospital would provide, and proposes the rationalisation of some smaller hospitals, which would be phased out. It concludes that full emergency services can be provided only in relatively few major high-volume hospitals. In order that the implementation process can commence as quickly as possible, the report recommends that the new proposals first be tried out in two health board areas: the East Coast Area Health Board and the Mid Western Health Board.

Sceptics would say that the main Hanly recommendations resemble those contained in previous health service reports, including the 1968 Fitzgerald report and the Tierney report, which never got off the ground.

Industrial relations 'flashpoints'

The main areas where the Hanly proposals are likely to run into industrial relations problems are set out below.

Renegotiating consultants' common contract

The Health Minister, Micheál Martin, has signalled his intention to seek renegotiation of the 'common contract' for hospital consultants, and this will be the critical element if the reforms are to proceed. Consultants have been holding meetings to discuss the issue. The post-Hanly consultant contract talks are expected to begin in mid-January 2004.

Pay and terms and conditions of employment for hospital consultants are negotiated about every three to four years under what is know as the common contract. Over recent years, the consultants have been included in the Buckley review, which sets pay for top public servants in Ireland (IE0103232N). The two have become intertwined, with common contract productivity talks followed by the Buckley review, which then puts a price on the outcome of the common contract talks. The next pay review is due in 2004. The renegotiation of the common contract on this occasion may be tortuous, especially as consultants are likely to seek substantial pay increases and compensation in return for agreeing to the Hanly proposals, which would require them to work more flexible rosters over a 24-hour period, and to rescind some private practice. To add to the potential difficulties, the IMO feels that common contract/pay review talks for consultants have been delayed in recent years. The IMO lodged a pay claim relating to this issue to the Labour Court early in 2003, but the Court refused to recommend further payment over and above that granted by the Pay Review Body.

Consultants want to be paid at least the same as a High Court judge and a secretary-general of a government department, citing the 'unprecedented level of change' that has occurred in the health service over recent years. In the last Buckley pay review of salaries for top public servants, published in September 2000 (No. 38) - having been delayed by one year - consultants were awarded a 10% interim increase, bringing the annual salary of a category two consultant to EUR 97,160-EUR 107,661, and a category one consultant to EUR 108,804-EUR 120,612 (the difference between category one and two is based on the mix between private and public work a consultant is prepared to do). In comparison, High Court judges were awarded an increase of almost 26%, bringing their salary to EUR 146,020, while secretaries-generals received increases of 15% to 33.3%, bringing their salaries to a maximum of EUR 133,322-EUR 171,415.

It was established at the time that any further increases for consultants over and above the Buckley interim award were to be agreed in productivity or common contract talks. However, such talks had to await the publication of the Medical Manpower Forum report, which was published late in January 2001. However, no negotiations on the substance of the common contract took place after the report was published. The negotiations have since been further delayed by the subsequent Hanly Task Force report on Medical Staffing, which arose out of the initial Medical Manpower Forum report.

In its defence, the employer side - the Health Service Employers Agency (HSEA) and the Department of Health- argues that none of the changes envisaged have yet been negotiated or put in place, and, therefore, the role of the consultants has not fundamentally altered. The implication is that a substantial pay increase has not, thus far, been warranted, and that any further increase on top of the Buckley 10% interim award will have to await the outcome of the common contract talks. The HSEA has also claimed that, to a large extent, the delays were caused by the unions setting down conditions for talks.

Reducing NCHD numbers/hours.

Reduction of the number of NCHDs, and of their working hours/overtime, is another potential industrial relations flashpoint, and was the subject of a major dispute in 2002 (IE0301207F). The IMO is sure to resist any downgrading in the earnings of its members - of which overtime constitutes a relatively large element - even in the event of reduced working hours. The HSEA argues that the IMO cannot have it both ways. The parties were due to attend conciliation talks at the Labour Relations Commission on 17 December 2003, in a bid to resolve their long-standing differences on this issue.

The interpretation of the application of overtime pay has continued to be a contentious issue between the IMO and the HSEA for a number of years. While the IMO argues that overtime should apply to any hours worked outside the core working hours of 09.00 to 17.00, Monday to Friday, the HSEA believes that overtime pay should only apply after 39 hours have been worked. The 2002 dispute was initially sparked when management attempted to change the basic working week of NCHDs, so that part of it takes place outside what the IMO says are the 39 core day-time working hours of 09.00-17.00, Monday-Thursday, and 09.00-16.00 on Friday. The HSEA says that changes to work rosters are necessary if the excessive overtime worked by doctors is to be reduced in line with the EU working time Directive. While, in principle, the IMO agrees that the hours of NCHDs need to be reduced, it argues that the core working week must remain 09.00-17.00, Monday-Thursday, and 09.00-16.00 on Friday, and that any work done outside these 39 hours should be paid as overtime. It will be difficult for the deadlock to be broken on this issue.

Negotiating change with other healthcare workers.

The Hanly proposals may also create industrial relations difficulties in other areas, due to the requirement to negotiate any knock-on changes affecting other health workers - including nurses, ambulance drivers, and administrators - which do not come under the umbrella of the modernisation provisions of Ireland's current national agreement, Sustaining Progress (IE0304201N and IE0301209F).

Commentary

It is clear that a number of major industrial relations hurdles will have to be cleared if the Hanly proposals are to be implemented in the Irish health service. These potential industrial relations flashpoints must also be viewed against the present more austere economic and financial backdrop, with the Department of Finance keen to rein in public sector spending. At the current juncture, it appears that there will be limited funds in the 2004 government estimates to pay for the Hanly reforms, especially given that a large chunk will go towards paying for pay increases due to public sector workers under the public service pay 'benchmarking' process (IE0207203N). In short, it is not clear where any additional funding will come from - for instance, to employ extra consultants. Elements of the report - such as the potential closure of some smaller local community hospitals - are already proving to be politically explosive and are sparking opposition, and unless there is sufficient political appetite, it seems unlikely that the report’s recommendations will be implemented in full. (Tony Dobbins, IRN)