Brennan Report - Department of Health and Children

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Report of the Commission on Financial Management and Control Systems in the Health Serviceimpede the full application of general principles of financial accountability by clinicians.Specifically:●●●Consultants are not required to account for the cost of resources consumed as a directconsequence of their clinical decisions.Existing arrangements allow Consultants to pursue both public and private practices(including during the 33-hour scheduled commitment under the Consultants’ publiccontract 2 ).The mixing of public and private treatments also restricts the time available to cliniciansto pursue resource management issues.Issues surrounding the public/private mix are discussed in more detail later in this Chapter.We are concerned at the lack of explicit detail in the Consultants’ contract concerning theirtime commitment to public patients. For example, the contract does not require an individualConsultant to discharge his responsibilities to public patients personally (see section 5.2 of thecontact and 2.11.2 of the Memorandum of Agreement in Appendix 7):"The consultant may discharge this responsibility directly in a personal relationship with hispatient, or, in the exercise of his clinical judgement, he may delegate aspects of thepatient's care to other appropriate staff". (Sn 5.2)"A consultant's time commitment, which will be personally discharged, will be scheduled insessions during the hours normally worked within the Monday to Friday working week. Therequirement to personally discharge all of the commitment does not preclude the consultantfrom delegating aspects of his scheduled work while the time commitment to (the employingauthority) is being personally discharged elsewhere." (Sn 2.11.2 – Memorandum of Agreement)We acknowledge that individual Consultants personally carry "the continuing responsibility forhis patients so long as they remain in his care". However, we note that the State pays up to 90%of the professional indemnity insurance for Consultants with a contract, so the risk whenprocedures go wrong is substantially carried by the taxpayer, and not by the consultantpersonally.The opportunity to earn additional monies through private practice, combined withthe ability to delegate public work to other staff, is not in the best interests of the Irishtaxpayer.At present, 47 Consultants have a contract, which commits them to work exclusively in thepublic sector. However, this option was withdrawn under the 1997 common contract. Weunderstand the Review Body on Higher Remuneration (Report No. 36) recommended abolitionof this category of contract. We also understand that this was not a popular contract optionamong Consultants (hence the small numbers exercising the option).2See Appendix 7, section 5.2 and section 2.11.2 of the Memorandum of Agreement to the Consultant Common Contract.66
Chapter 5 Accountability – Hospital and Non-Hospital ProgrammesRecommendation on the existing Consultants’ Common ContractR5.2 The Consultants’ common contract should be reviewed, for existing Consultants, to ensure that the followingprinciples are explicitly reflected in the contract:● Formal recognition and agreement by Consultants, as the key decision makers, of their responsibility tomanage resources to which they are entitled to conduct their practice 3 within agreed budgets atdepartment, specialty and individual Consultant level.● Participation in arrangements for collective representation of Consultants at hospital managementcommittee level.● Agreement of core hours of attendance.● Active management and optimisation by Consultants of resource allocation against agreed practice,specialty and department Service Plans and budgets.● Cooperation with arrangements for measurable and transparent systems of continuously monitoringadherence to public and private practice contractual commitments.● Where there are competing public and private practice demands on Consultants’ time and resources, theformer should have priority call on such time and resources at all times.The progressive implementation of the EU Working Time Directive over the coming years islikely to give rise to recruitment of a large number of additional Consultants. This presents aunique opportunity to recruit a substantial proportion of Consultants on a "public-only"contract. This would go a substantial way towards addressing the conflict of interest issueidentified above and make sufficient time available to Consultants to fully engage in financialmanagement and practice budgeting.In this context, we would emphasise that such a move would be consistent with Governmentpolicy, as reflected in the health strategy, to target public resources towards public patients. Inparticular in the health strategy 4 , the Government has decided that there will be aprogressive reduction in the proportion of private to public beds in the public hospital setting.It has decided that all new general hospital beds under the Bed Capacity Programme will bedesignated as exclusively for the use and treatment of public patients. Seven hundred beds arecurrently being put in place in public hospitals on this basis.Recommendation on Contract for New Consultant AppointmentsR5.3 All new Consultant appointments, covering new posts and the replacement of existing Consultants, should be onthe basis of contracting the Consultants to work exclusively in the public sector.Executive Management CommitteeIf clinical Consultants are to become central to the structuring of accountability for themanagement and control of resources in the general hospital programme, it will be essential tohave appropriate management structures and processes to enable them exercise thataccountability in ways that will benefit their patients through the more effective use ofresources. It is imperative that all hospital management structures include an ExecutiveManagement Committee that involves representation of clinical Consultants in themanagement of the hospital. The Executive Management Committee will provide a forum forclinicians to have an input into, and be accountable for, managing the hospital resources and todiscuss clinical and management concerns.3Section 6.4.4. - Consultant Common Contract 1997 (See Appendix 7).4”Quality and Fairness – A Health System for You” (page 107).67
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Commission onFinancial Managementan
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TABLE OF CONTENTSEXECUTIVE SUMMARY
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6.4 COMMUNITY DRUG SCHEMES 80Medica
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Executive SummaryEXECUTIVE SUMMARYT
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Executive SummaryWe do not underest
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Executive Summary"demand-led" schem
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Terms of ReferenceTERMS OF REFERENC
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GlossaryEstimates for Public Servic
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Chapter 11 ImplementationRecommenda
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Chapter 11 Implementationbeing brou
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Appendix 1Appendix 1COMMISSION MEMB
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Appendix 1He has held this position
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Appendix 2SIPTU*South Eastern Healt
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Appendix 3Name of AgencyBord na Rad
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Appendix 3Name of AgencyIrish Blood
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Appendix 3Name of AgencyWomen’s H
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Appendix 4Department of Health and
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Appendix 4collated and assessed by
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Appendix 4The most detailed element
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Appendix 4Ratifying and Submitting
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Appendix 4changes to the Service Pl
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Appendix 4advised of their existenc
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Appendix 4Approvals Required in lin
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Appendix 5Appendix 5DIAGNOSIS RELAT
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Appendix 5Figure: Ax.1 Casemix Adju
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Appendix 6Appendix 6AUDIT OF STRUCT
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Appendix 7(vii)(viii)(ix)participat
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Appendix 8Appendix 8 - Integrated M
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ADDENDUMNumber Recommendation IT Ti
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Brennan Report - Department of Health and Children

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