Subscriber OnlyOpinion

Fintan O’Toole: Ireland’s dysfunctional health service crushes idealism and rewards cynicism

Why is the culture so resistant to positive change? Three historical reasons suggest themselves

Sum up the culture of the Irish public hospital system in two words? Learned helplessness.

Like most readers, I have friends and acquaintances who are frontline nurses and backroom administrators, cleaners and porters, middle managers and consultants.

And if I ask them about their working environments, they all use the same word: dysfunctional. They’ve all got used to a constant low-level hum of despair about the pervading culture.

It’s a low-level hum because nobody wants to talk about it in public. It’s another of the unknown knowns of Irish society.


Everybody knows there are profound problems of passive management, demoralised staff and institutional sclerosis. But, for honourable reasons, nobody wants to say this too openly for fear of talking down the system or betraying their colleagues.

It’s important to stress, first of all, that the primary problems are structural: too few hospital beds, too few health professionals, the woefully slow roll-out of the Sláintecare reforms, the inequities and opacities of two-tier healthcare, the chronic underfunding of community and home treatment.

Yet the starkness of these deficits makes it far too easy to make excuses for failures to use existing resources for the maximum benefit of patients. The hardware of the healthcare system is undoubtedly inadequate. But so is the software: the way people work with what they do have.

What you will hear if you talk to those people is that staff come in four varieties: the enthusiastic, the chastened, the burned-out and the cynical. Often these are the stages of the life cycle of the same healthcare worker.

Most people who go into the system really want to do a good job. They start out with idealism and commitment. As they learn the ropes, they see how things could be done better, more efficiently and more humanely. They think they can make these changes happen. And then they’re buried under the inertia of the other three kinds of people.

The chastened are the enthusiastic a few years on. They banged their heads off the wall until the wall declared victory. They are resigned to doing their best within the limits of the status quo.

The burned-out are the enthusiasts who refused to be defeated. They take on the work that others are not doing properly. They accept responsibilities well beyond their pay grades. They work themselves to the bone for the sake of the patients. And the system sucks the life out of them.

All three of these categories can join the ranks of the cynical, though there are always a few people who start out there in the first place. These are the people who either never gave a damn or don’t do so any more.

What anyone who works in the system will tell you is that there is no penalty for cynicism. If you’re a low-level worker who can’t be bothered, your colleagues and supervisors just have to find a way to take up the slack.

If you’re a manager who is useless, you may eventually be demoted to a less responsible job – but keep your salary, pensions and entitlements. Almost nobody is ever fired.

High-level managers are too distanced from the day-to-day operation of hospitals to have to confront any of these problems. The middle managers who keep the hospitals going are too mired in crisis management to take on the hassle of firing an incompetent worker or changing work practices to make things better for patients.

They have no confidence that their superiors will support them if they cause “trouble”. So the whole system is less about working than working around. The good people – and they are the large majority at every level – work around the bad practices.

Why is it like this? Three historical reasons suggest themselves.

One is that the hospital system was built on an alliance of religious orders and consultants. The first group has a direct line to God, the second is God. Gods don’t do accountability – and if you don’t have a culture of accountability at the top, you won’t have it all the way down.

Second, there was patronage. A lot of lower-level hospital jobs were handed out informally through political and familial connections. (Fianna Fáil in particular had a lock on entry to areas such as portering.) Patronage creates a corrupt culture of entitlement that can be hard to root out.

Third, there is opacity. It is beyond belief that in 2023 most of our hospitals are still run with pens and paper. How can you manage a complex system and create personal accountability when there is no real-time data to show exactly what’s going on?

This culture has to be confronted. Of course the system needs both expansion and structural reform. But it also needs a working environment in which enthusiasm is not crushed, energy is not burned out, cynicism is not rewarded, incompetence is not protected and managers don’t think it wisest to keep their heads down.

This won’t happen until the frustrations of those at every level of the system are given voice. They know better than anyone else that more money is not the only treatment the system needs. A dysfunctional culture may be a symptom of wider failures but it is also a cause.