SECOND OPINION:More open dialogue is needed to manage the system, writes DESMOND O'NEILL
THE IRISH are hard on their politicians, with a rancour that is almost certainly fuelled by a subconscious recognition that they reflect our national characteristics, and by extension ourselves, only too well. In keeping with our love of wordplay and a constitution based more on property rights than community spirit, much of our political debate is characterised by ambivalence and the unspoken, and our level of consensus and fair play eroded by clientelism and individualism.
As a result, we have grown too habituated to vagueness about entitlements and provision of services, and allowed our system to disincentivise those who know better to speak up. Hence, the nursing home charges scandal and the problems with fractionation of specialist and complex services such as cancer and general hospital care.
The challenge of making a change in this particularly Irish societal logjam was beautifully caught nearly 80 years ago in Lennox Robinson’s Drama at Inish. Set alight by the brooding introspectivity of Chekhov performed by a visiting theatre troupe, the population of a small Irish village start thinking, debating and being honest with devastating effect – the local TD votes with his conscience, and brings down the government (how topical can you get!). The resignation of Mary Harney affords a contemporary parallel, with an opportunity to see what happens when an activist and an ideologue (not necessarily a pejorative term, but the Irish don’t really “do” ideology) engages with the system.
We need to move beyond the lazy temptation to use her prominence as a lightning rod for all our discontents with the health and political system – did we really prefer the ducking, diving and weaving of her predecessors, and did we really think that the Opposition was willing to challenge the paradox that the Irish wanted both low taxation and good services by proposing higher taxes during the good years? Did we object when Bertie Ahern compromised the HSE from the get-go by assuring that no managerial staff would lose their positions (and keep their increments)?
There are very many significant achievements from her tenure, the most lasting of which will almost certainly be the first major move to finally remove the dust from the Fitzgerald report (1968) and recognise that we cannot provide all complex hospital care on 37 sites. Aided by the cancer scandals and not being hampered by backbenchers timorous about re-election, she has moved this agenda in a way unthinkable a decade ago.
For older people there is a mixed scorecard. Perhaps the most important initiative is the establishment of Home Care Packages in 2006, a very important benefit albeit requiring further development and regulation. Also, the setting up of Hiqa and independent regulation of nursing homes (private and public) has been a major improvement, as has the development of a network of case workers to manage elder abuse.
On the downside, older people have been the victims of the twin ideologies of co-payment and “private-sector good/public-sector inefficient”, and our failure to develop a structured debate and consensus on the implications of this.
In the first instance, this has led to an apartheid of illnesses relevant to later life – if you have cancer or heart disease, no financial barrier to your care plan: if you have stroke or dementia, be prepared to dig deep for your care plans. Indeed, the perils of looking for clarity piecemeal become apparent – you may not like what you see, especially if it taps into deep and subtle ageism inherent in our government, one which portrays older people as a burden, rather than valued citizens.
The emphasis on privatisation has encouraged the HSE not only to neglect renewal of our public nursing homes, but also the evolving scandal of them allowing them to be closed on the basis of poor care standards – as with Loughloe House and Sir Patrick Duns – without major investigation of how on earth this can happen.
At the end of Drama at Inish, the townspeople turn their backs on profundity and troop off to the circus (a further prescient foresight of the political events of the last week). The challenge of Mary Harney’s legacy is not to revert to the usual circus, but to engage seriously with the drama of managing our health system with a more open dialogue, a fuller discussion of impact of major privatisation ahead of its implementation, and better recognition of damaging prejudices (such as ageism) and the broad range of competing interests which influence our actions.
Prof Desmond O’Neill is a consultant in geriatric and stroke medicine