Iremember having a conversation with an official at the Department of Finance a few years ago about health service spending. It was early in 2003, when the cuts that were brought about by the earlier pre-election spending spree were really beginning to bite hard.

I was on a group making the case for a particular programme to be kept. We expected the mother of all battles to hold on to the budget we’d had the previous year. Everyone else’s was being cut, so why not ours? It proved surprisingly easy in the end, not because our cause was more deserving than any other, or even because Finance was going soft that New Year. It was, as my opposite number put it that day, because the word from “across town” was that health wasn’t to be touched.

Health spending remains sacrosanct in political terms. Among the public, however, there is increasing scepticism about whether, on balance, the services are better or worse as a result of investment and ‘reform’. While the sector has emerged yet again as the big winner in the recent Budget, hopes that the change process would get a much-needed boost as a result of successful talks on the consultant contract are fading.

Reform here is only part of the picture, of course, but it is an important part all the same, not least because of its signalling potential.

Pretence of progress

While none of the sides will wish to collapse the process because of the poor light in which they would inevitably be seen, the question many are asking is how long is it possible to keep up the pretence of progress?

Consultants are now convinced that the HSE is dealing from the bottom of the pack in tabling proposals that deal substantively with the public-only post, rather than the menu of options that had been promised in an effort to kick start the talks. Given that backdrop, it’s hard to see how committees set up to tackle key issues will be able to make progress.

The HSE is adamant that it hasn’t rigged the game, but there can be no doubt that its strategy to push for a public-only contract at the start of the talks is indicative, not just of its desire to see such a post created, but to alter radically the balance of power between providers and the funder.

Reports in the media, that public-only consultants would be paid a salary of €250,000 to €300,000 or more, will undoubtedly tempt many that would have little to gain from private practice, but the fear for the negotiators is that the real price will not be better pay and conditions for some consultants, but subjugation and serfdom for the entire profession.

It’s impossible to tell at this time whether, or for how long, the representative organisations will be prepared to continue the talks, not least because they still have no idea how a contract will be priced.

Without that knowledge, and in the absence of discussion and agreement on the other core issues, they can’t make a deal or give a recommendation. In addition, with a general election getting near, neither of the governing parties will want to risk a potentially-damaging confrontation that would further fuel the public perception that all of the extra money is not making an appreciable and positive difference to the health services.

Public dissatisfaction

The Minister for Finance has gone out of his way in the Budget to continue the investment and to try to contain the mounting public dissatisfaction, as evidenced in focus group discussions and opinion polls. What happens after the general election will depend in large measure on the complexion of a new government and, in that context, whether a new administration might risk a radical new direction.

Suppose that were to happen? Suppose a new government was to try a radically different funding model — based, perhaps, on a hybrid model of general taxation for capital developments and social insurance for the provision of services — what then would be the future for the contract?

For now, it looks like track cycling at the Olympics; the three main riders watch each other’s every move, while keeping a weather eye open for a possible burst of speed from one of the main political parties. None would want to be caught short in the ensuing sprint for the line, especially if some of the parties had taken a chance and offered voters a real alternative on the funding and organisation of services.

While that may seem an unlikely scenario at this point, in politics anything is possible. It could even be an attractive path into government for an opposition which is struggling for relevance and resonance with the voters. But it would be disastrous for consultants if their representatives had not fully prepared for such a dramatic shift in the political ground.