Brennan Report - Department of Health and Children

Chapter 5 Accountability – Hospital and Non-Hospital Programmesactivity. Case studies performed in a number of jurisdictions highlight the positive repercussionsof providing this information to clinicians, in a way that is appropriate and sensitive to medicalpractice.During their meeting with us, representatives of the Irish Hospital Consultants Associationindicated their support for initiatives to have their members play a meaningful role in hospitalmanagement structures.Clinical Independence and its Implications for Clinical BudgetsThe major obstacle experienced to date in creating a financial planning, management andcontrol model to 'fit' services provided by clinical Consultants appears to have been theinterpretation put on clinical independence of Consultants.This is covered in section 5.2 of theConsultants’ common contract (see Appendix 7) which states that "being a Consultant involvescontinuing responsibility for investigation and for the treatment of patients without supervision inprofessional matters by any other person."In the absence of agreed mechanisms for planning and managing resources, attempts tointroduce cost reductions or to increase efficiency may be met with resistance because they areperceived to interfere with the clinical autonomy of Consultants. Clinical independence orautonomy appears to be the distinctive feature of general hospital services which has defeatedthe application of conventional financial and management accounting systems to hospitalexpenditure in the past.The difficulty lies in being able to describe the nature of the accountability of Clinicians for theresources they use in making clinically independent decisions. It also lies in being able to agreewithin the terms of the Consultants’ contract how that accountability can be discharged in away that is acceptable to both parties.Consultants’ Common ContractWe consider clinical Consultants to be the key decision makers affecting expenditure inhospitals.We believe that, even though resource management is already part of the Consultants’common contract (See Appendix 7, section 6.2), resource management responsibilities are notbeing systematically and uniformly discharged because of the absence of appropriatemechanisms for planning outputs and budgets and monitoring expenditure. We find thewording in the contract relating to Consultants’ responsibilities for resource management to besomewhat vague and lacking in explicit detail. For example:"agreeing with management the details of the service levels and mix to be provided with in thescheduled commitment" (Sn 6.2(v))"providing information to (the employing authority) including data for hospital informationsystems and service planning and for such other purposes as (the employing authority) and youagree are appropriate." (Sn 6.2(ix))The individual contracts of Consultants give them the right to the resources they need topractice in their respective hospitals. As a consequence, we believe that the management ofthese resources needs to be grounded on individual accountability for how they are used.TheConsultants’ common contract as it currently stands contains inherent weaknesses that65