The aim of the new contract for hospital consultants is to have greater availability of these vital specialists to the public hospital system and patients, including at weekends.
For the first time consultants would be rostered on Saturdays.
Currently the public hospital system winds down a lot at weekends and is a different service to that seen from Monday to Friday.
Weekends are largely about monitoring patients and emergency surgeries but not planned operations and much of the time patients have to wait until Monday to be discharged.
That often leads to significant hospital overcrowding at the start of each week.
Talks between the consultant organisations and the Government on a more modern contract started in January 2020 and effectively lasted 18 months.
Those talks were held under an independent chairperson.
The consultants say that the talks were concluded late last year by the Government, without agreement and that they were presented with a final take it or leave it document.
The Department of Health has insisted that the talks were concluded by the independent chair who said no more could be achieved by negotiations.
The ballot by the Irish Medical Organisation and the survey by the Irish Hospital Consultants Association this week both rejected the new contract offer.
The contract went live from Wednesday and is the only contract that the State will now offer new consultants, consultants wishing to move from their existing contract, or consultants moving employer.
So it is very much a wait and see period now to establish how many consultants will actually take the new deal, which offers a basic salary scale range from €214,113 to €257,193 plus significant other payments for being on call, a twilight premium, overtime payments for certain agreed overtime work and Sunday and public holiday premia.
There is also money available to consultants for research and professional development.
Consultants who sign up will be working full-time in the public hospital system and cannot do private work there.
But they can do private work elsewhere, in their own time.
This means that they can potentially earn significantly in excess of the public salary, with extra private income.
Read more: IMO members reject new consultant contract in ballot
Five to 10 years
Minister for Health Stephen Donnelly said this week that the new contract is a major change in the way the public health services will be run.
It is a move towards the key health reform of ending private practice in public hospitals and achieving universal healthcare.
In truth, that will take perhaps five to 10 years because it will be a long time before a large body of hospital consultants are on the new contract, sufficient to have a uniform impact across the country in all specialties.
Minister Donnelly said it will mean more availability of consultants for patients and for doctors and nurses seeking advice from these top specialists, especially at weekends.
He pointed to the record hospital overcrowding in January after which the HSE secured temporary emergency weekend rostering of consultants which resulted in a 50% reduction in the number of patients on trolleys.
Minister Donnelly said that the negotiations were held in good faith, that the consultants fought hard and that on several occasions he went back to Cabinet to get material changes that had been sought by the specialists.
He said the new contract works for patients and for doctors and allows for family-friendly working hours too.
The new HSE Chief, Bernard Gloster said this week that it is a very attractive new contract and that nobody in negotiations can get all they want.
Consultants are a powerful group and the hospital system cannot operate without them.
"The IMO also has a lack of trust in Government and the HSE that there will be sufficient medical and other staff on at weekends and evening shifts to ensure safety"
Irish Medical Organisation
The Irish Medical Organisation said that most current consultants will not take up the new offer, most of the non-consultant hospital doctors, who are the future consultants, say they will not go for it and also that most consultants currently working overseas say they will not return to Ireland to sign up.
So this situation poses a real challenge for the Government and the health system. Where does it leave patients who must wait and see what happens?
The main problem raised by the IMO is that the new contract has no limit on the number of evenings and Saturdays a consultant will be required to work, in addition to already onerous on-call commitments.
It also said there is significant concern over the ability of the HSE to change the work location of consultants, without agreement.
The IMO also has a lack of trust in Government and the HSE that there will be sufficient medical and other staff on at weekends and evening shifts to ensure safety.
It insists the rejection is not a rejection of the salary level.
The Department of Health told RTÉ News that the Irish Hospital Consultants Association had expressed a concern that it was unclear whether consultants who opted to work part-time under the contract would be eligible for overtime.
The Department told the consultants that it was a well-established public service pay norm that people do not get overtime pay rates below the standard working week of 37 hours.
The standard week under the new contract is 37 hours.
The IHCA also claimed the disciplinary code was flawed.
The Department has insisted that the disciplinary process mirrors the disciplinary processes that are in place for all health service employees.
'Fair and balanced mechanisms'
In relation to the concern that the HSE might change the provisions of a consultants' contract in the future, the Department said that a contract of employment is made at a point in time but can remain in effect for decades.
It said it needs to be designed with enough flexibility to allow it to encompass changes over time, without the need to be negotiated to address every changing circumstance.
The Department pointed out that in a contract that lasts for decades, it may be the case that duties or locations of work can change over time. It says the new deal provides for fair and balanced mechanisms for such changes.
As regards the consultants concern over no limit on the number of late evenings and Saturdays a doctor may have to work, the Department said that the contract recognises the need for employers to be compliant with working time and other health and safety legislation.
The new contract will also have an impact on the income for public hospitals over time.
These hospitals derive significant money from the private practice of consultants via patient charges for beds, scans and tests.
"The focus must be on quality patient care; by having consultants available on a 24/7 basis and having a pool of consultants to deliver this"
Loss of income
The All-Party Slaintecare Report in 2017 put the potential loss of income for public hospitals at almost €650m a year.
If that money is not replaced for public hospitals, it could impact public patient services.
So there is a lot at stake in relation to the new contract and how it may improve the experience of patients.
It will also have an impact on the 900 vacant consultant posts and when they might be filled.
There will be an impact on public hospital waiting lists, now at over 820,000 patients, if the appointment of vacant and new consultant posts slows down over the disagreement with the new deal on offer.
The Irish Patients Association is not impressed with the attitude of consultants.
Stephen McMahon said: "Let's be honest the amounts of money on the table for consultants are eye-watering for a 37 hour week.
"The focus must be on quality patient care; by having consultants available on a 24/7 basis and having a pool of consultants to deliver this.
"Public patients deserve nothing less than a consultant-delivered services. Let's get this moving for all patients."
The ultimate aim of the new contract and other changes is that public hospitals will just be for public patients.
Access will not depend on ability to pay, but rather medical need.
The public hospital charges for patients staying in these hospitals are due to end in April under legislation approved by Cabinet this week.
All these changes are intricately tied up with the long promised Sláintecare health reforms.
So a resolution is very important for patients who rely on the public health system.