Public-only hospital contracts: HSE audit says rollout risked failure due to lack of oversight

Compiled in March — and released now under FOI in the wake of the Rotunda row — the HSE internal audit found there was ‘no structured framework’ to phasing out private care in public hospitals. Picture: iStock

The lack of any coherent oversight of the phasing out of private consultancy care in public hospitals “increases the risk of failure” of the public-only contract, a HSE audit has found.

The internal audit report, published in March and released under the Freedom of Information Act, found there is “no structured national or regional reporting framework to monitor” either the phasing out of private care in public hospitals or the “achievement of enhanced roster flexibilities” planned for in the new public-only consultancy contract issued by the HSE in 2023.

“This increases the risks of failure to achieve the benefits of the contract and failure to achieve value for money,” the audit report said. It found the adequacy of the contract’s governance and control to be “unsatisfactory”.

The 2023 contract was introduced as one of the pillars of Sláintecare, the 2017 cross-party healthcare plan designed to remove private practice from public hospitals and to do away with Ireland’s two-tier healthcare system.

Rotunda row highlighted the issue 

It has been a source of considerable controversy in recent weeks after the board of the Rotunda Maternity Hospital in Dublin admitted before the Oireachtas that it had continued to allow consultants on the public-only contract to deliver private care within the hospital grounds despite the contract precluding them from doing so.

After a week-long stand-off with health minister Jennifer Carroll MacNeill, the Rotunda’s board backed down earlier this week and said public-only consultants would no longer be permitted to conduct their private business on the premises.

However, the audit report shows that, despite the new public-only contract being introduced three years ago, there has been little change in the levels of consultants providing services to patients at weekends or at unsociable hours on weekdays, indicating “limited realisation of contract flexibilities”.

The report instead notes consultants on public-only contracts tend to work the same hours broadly as those on non-public-only contracts.

Under the newer contract, consultants can be asked to work at any time between 8am and 10pm Monday to Friday, and between 8am and 6pm on Saturdays as part of their core 37-hour week.

The audit said the fact that little of those abnormal working hours are being satisfied by the contract indicates that the lack of “enabling operational conditions” to support the consultants — such as available theatres, doctors, and nurses — has “not been adequately addressed”.

Roughly 70% of Ireland’s more than 4,000 consultants have signed up to the public-only contract to date.

The contract is remunerated at a scale ranging from €231,000 to €278,000 on a six-point scale, with additional pay for on-call duties and additional “premium payments” for those eligible.

The HSE audit recommended, as a high-priority, that a new framework be introduced by the organisation’s chief people officer to enable formal national governance and reporting on the implementation of the public-only contract. The recommendation was fully accepted.

Eight patients elected to remain in private care

In the wake of the week-long controversy at the Rotunda Hospital, the institution said just eight of its patients had elected to remain in private care after their consultants were instructed to cease seeing them on the hospital grounds.

The hospital’s board acceded to the health minister’s demands after she indicated that State funding could be withdrawn should its consultants — roughly half of whom had signed up to the public-only contract — not comply with its provisions in full.      

A statement from the HSE said: "Clinical sites are continuing to enter Consultant Work Practice Plan (WPP) information into the HSE’s central Doctors Integrated Management E-System (DIME). Since the internal audit report was completed, the number of WPPs recorded has grown significantly with 4,134 (83.62%) plans on the DIME system.

"Since completion of the initial Internal Audit report, more consultant plans now include evening and Saturday work. Making the most of the flexibility available under POCC 2023, and delivering benefits to services, remains a key priority for HSE senior leaders and regional management teams.

"A national governance framework is currently being developed to oversee the removal of private practice from public hospitals with data collection underway in this regard."