The ongoing row involving the Health Service Executive and the St Vincent's Healthcare Group stems in part from tensions between the traditional voluntary hospital system that operated in Ireland for decades and the centralised system of administering healthcare that emerged in recent years.
Over the last year or so the group that runs St Vincent's and St Michael's public hospitals in south Dublin, as well as St Vincent's Private Hospital, has clashed over executive pay, governance and consultants' private-practice rights.
However, the move yesterday by HSE director general Tony O'Brien to send forensic auditors to look at the internal workings of the group brings the dispute to a new level.
Under the traditional funding model the State provided hundreds of millions of euro annually to voluntary hospitals to provide patient services. However, the voluntary hospitals are run by their own boards, not the HSE, and have traditionally jealously guarded their independence.
The management and staff in these institutions are considered to be public servants. They have the same job security as other State employees and enjoy defined- benefit pensions, which are becoming increasingly rare in the private sector.
Such a system was probably inevitably going to clash with the HSE, which was established to run the health service as a national organisation.
Additional payments
In 2013
The Irish Times
revealed that although considered to be public servants, senior executives in a number of voluntary hospitals and agencies were receiving more than €3 million between them in additional payments and benefits on top of their official remuneration.
Even within the voluntary hospital structure the St Vincent’s Healthcare Group is unusual in that it operates not only two public hospitals but also a private hospital. It had been paying senior executives additional money to work for the private hospital in addition to duties in the public facilities.
The HSE and later the Oireachtas Public Accounts Committee became involved in a lengthy wrangle over whether such a move breached Government public pay rules. Eventually executive salaries in the group were brought into line with official policy.
Consultants’ contracts
Another major issue between the HSE and the group centred on consultants with contracts in the public hospital working in the private facility.
Under contractual rules consultants with a category-B contract can see private patients in a public facility only.
The HSE last month claimed 56 per cent of consultants admitting patients to St Vincent’s Private Hospital did not have contractual rights to do so. This has been strongly rejected by the group. The HSE also contended that serious outstanding issues remained concerning overall governance arrangements in St Vincent’s Healthcare Group .
The issue of the independence of voluntary hospitals and their relationship with the HSE and Government is not just a philosophical argument. It will have to be addressed before the Government can fully implement the next phase of its healthcare plan, the establishment of hospital groups and, later, hospital trusts.
The main issue that will have to be determined is where the boundaries will be drawn between powers of voluntary hospitals with their own boards and the broader regional groups of hospitals established by the Government, which will also have their own authorities.
Who will, in such circumstances, have the ultimate authority? And how will they relate to the HSE,which despite previous plans for it to be abolished seems positioned to remain in existence for the immediate future at least?
Minister for Health Leo Varadkar has said the first hospital trust, involving the three children's hospitals, will be established in the months ahead. Policy decisions in this area will need to be taken quite soon.
