We see the world from where we stand - so it is with our health service. Sometimes we never look at our health service until we need it and then it may be too late.

The current two-sided debate - the nurses versus the Minister and management - will continue to be just that unless we are prepared to look at what is happening on the ground and what has been a growing, festering, poor service for a long time.

We have all joined in some way in the criticism of church and State over the treatment of young people earlier this century. The church was happy to take on the role and the State was happy to let it.

Exactly the same thing is happening with healthcare. The State is offloading its responsibilities for the care of people to a voluntary sector which is happy to do the work. A growing voluntary sector, receiving money from Europe, is as a result unable to look critically at its position. The current rush is to set up partnerships, where debate is so often stifled and where any attempt to question or have a different point of view is seen as not being progressive enough.

Partnerships and European funding on the one hand look good, with more research, more assessment, more conferences, more jargon, but are we any nearer to assessing what is happening on the ground?

Many sad stories continue to make headlines and the simple interventions that could ensure some old person continues to live in the comfort of their own home are being ignored.

There are people waiting for orthopaedic surgery, people waiting for cataract surgery - confined to their homes unable to read or watch television and fearful of opening the door, not recognising the shadow.

There are people over 65, needing more than three chiropody sessions a year, unable to put on their shoes because the highly-paid doctor in an administrative position decides they don't need it.

The alcoholic who after many years sleeping out decides he will avail of treatment is offered only strong tranquilisers in a day centre and a park bench to lie on.

In 1974 I carried out a report "Medical Care for the Vagrant in Ireland". It highlights how little has changed: "Jervis Street Drug Unit had contact mainly with young drug addicts. Here, they are in a powerful preventative position recognised in the recommendation from the unit for a night shelter for this age group with minimum institutionalisation."

The elderly man, needing a diet supplement, is unable to get it without expensive blood tests because it is too expensive, yet a younger, ablebodied person can get all he wants and give it away.

The young man, whose skin on his buttocks is like raw steak from sleeping out in all weather and urinating, can be offered only a prescription and one night in an emergency hostel because he is not ill enough for hospital and not suitable for convalescence because he has no address.

The report on vagrancy also said: "Up to four or five years ago, we did not find it difficult to arrange admission to hospital for men who needed such treatment . . . the position since has become alarming . . . our recent experiences in trying to get needed hospital treatment for our sick men are very disturbing." Since 1974 what, if anything, has changed?

We received a phone call in TRUST from a man known to us who was last seen when he was barred from a city hostel and later picked up by ambulance when sleeping rough. He was subsequently paralysed and as no suitable accommodation was found for him in his home city he was sent to a nursing home in the south-east. The call came as a surprise. Could we help to sort out his pension and send him clothes?

Last week a student nurse was asked on the radio what she did by an interviewer who might earn more opening a supermarket or conference on healthcare than the student would in six months. This highlights how we view the simple things that make life easier for a patient - washing them, touching them, soothing them, reassuring them. Piped music and monitors cannot replace the human touch.

The student was clearly too embarrassed to talk about what society now takes for granted and sees as being of no importance.

The human condition does not change but how we deal with its needs can. Relatives have to visit patients before going to work to ensure those nearest and dearest to them have breakfast and a wash.

People are now being cared for by people recruited by advertisements offering salaries of £11,000 and part of their responsibility is to administer dangerous medication. Who is responsible if things go wrong? It would appear that more and more management posts are being filled but I wonder what there will be to manage soon. People are discharged from hospital with prescriptions, unable to have them filled.

People have to ring up daily to see if there is a bed vacant; sometimes, having planned admission, surgery is cancelled.

People are lying on trollies in overcrowded, dirty, outpatient departments and are sometimes seen as the problem because they become abusive.

It is unlikely that payment to nurses alone will solve this problem; the health services need a complete root and branch overhaul. The focus of research perhaps needs to change radically.

Recently men living in hostels were given £20 to fill in a questionnaire on their social history and later £15 to have an X-ray and blood tests for research purposes - just two pieces of research carried out at great expense. Should anything be discovered requiring hospitalisation will there be a bed waiting? People needing X-rays for other purposes must wait. Tired and weary service-providers are sometimes even seen as part of the problem by diligent researchers.

Daily I see scabies, head lice, wounds, trench foot, TB, malnutrition, impetigo, pain and bitter tears of sadness. I see pockets full of expensive medication.

I read daily of working groups, strategies, research findings and seminars and now appeals once more to all to tighten our belts to ensure our economy and our health services survive.

Our economy is ignoring many citizens who contribute to its prosperity who are likely to end up like some of those I refer to. History will judge us to be no better than those we have condemned in States of Fear and many poorly-paid service-providers of today who become ill have little to look forward to.

There are many concerned, aware people in the health service and many who are afraid to complain. Life can become difficult if you do, or if you are a complaining recipient of services. Much more trust is required at all levels and in the trade union movement if we are to achieve a health service where all will get the attention they need.

Alice Leahy, the co-founder and director of TRUST, is co-author with Anne Dempsey of Not Just a Bed for the Night (Marino Books).