LEO Varadkar is ashamed, and well he might be. On Thursday, following the publication of a report into the deaths of five babies at Portlaoise hospital, the health minister proclaimed himself ashamed of the treatment of patients there.
“I am ashamed at the manner in which patients were treated without respect, care and compassion when they most needed it, by members of my own profession and other professions,” he told an Oireachtas committee.
Reaction elsewhere has followed a trend. In the Dáil, there have been expressions of anger at a State that treats its citizens in this manner. The media has been beside itself with outrage as well. There is plenty of blame to go around. There were, and possibly still are, specific problems in Portlaoise, but there is a much bigger picture that few want to talk about. Any proper analysis of why scandals keep emerging from within our health system has to accept that society at large has major questions to answer. In particular, why is politics allowed to dictate the provision of healthcare in this country in a manner that is detrimental to the nation’s health?
For more than 40 years, there have been attempts to rationalise the number of hospitals. This is a matter of nothing more than common sense. Fewer hospitals mean more resources concentrated in fewer locations, and greater throughput of cases. This enhances experience, and cultivates expertise. This is the case in maternity, emergency departments (EDs), cancer care, or whatever. All of which leads to better health and lower mortality rates.
That’s the theory. And, every so often, reports are compiled by people who work in this area, telling governments what needs to be done for the sake of the nation’s health. One such report said that there were too many small hospitals in the State — 51 at the time — and a lack of co-ordination between them.
It recommended the establishment of four regional hospitals, supported by 12 general hospitals, with the remaining hospitals downgraded to health centres and community facilities. That report, chaired by a Prof Patrick Fitzgerald, was published in 1968. As health policy analyst, Sara Burke, wrote of it: “The report generated considerable opposition from communities where hospitals were to be downgraded, and from the management of voluntary hsopitals who rejected losing autonomy. The 1970 Health Act did not adopt Fitzgerald’s recommendations and the proposed reconfiguration of hospitals never happened.”
That report was the first of many, which all broadly said the same thing. Yet, precious little has changed. Earlier this week, the Irish Association of Emergency Medicine reported that the State has far too many ED facilities. The report stated that political considerations on whether to maintain services “seemed to take precedence over all other matters, particularly patient safety concerns”.
The IAEM’s Fergal Hickey told RTÉ Radio that the system needed to be reconfigured. “Our difficulty is that we have 29 emergency departments in the country, which we simply cannot sustain. And there’s no point in us continuing to claim that we have this service, when the reality is different,” he said.
When Dr Hickey advises his patients on their health, they listen. When he advises society on its health, it turns a deaf ear. And don’t expect politicians to listen to a doctor in a year of election. People die all the time, but elections only come around once every four or five years.
The Hiqa report into the Portlaoise maternity deaths provided another searing example of the politics of health in this country. Hiqa’s draft report stated that, in 2012, the hospital was due to have its 24-hour facility downgraded. There was holy war. Local TD Charlie Flanagan sat in on an Oireachtas health committee meeting and made the case for retention. The then health minister, James Reilly, said it was not government policy to downgrade Portlaoise.
At the time, the Government was reeling from the defection of Roscommon TD, Denis Naughton, who had resigned because he said he couldn’t stand over the decision to downgrade the local ED. Naughton’s decision made him a local hero. He will waltz in at the next election.
His constituency and former party colleague Frank Feighan will struggle. Feighan accepted his Government’s decision. One might well ask which of them did more for the health of the people of Roscommon.
When politics clashes with health, all actions are informed by perceptions rather than reality. Everybody wants a building on their doorsteps that advertises itself as a hospital. Everybody wants that building to preferably operate on a 24-hour basis. It doesn’t matter if people who know about these things tell you that your health, and that of your children, or your parents, or your community, is better-served by having a proper hospital a further distance away. All that matters is perception. And perception, like promises, is the staple of politics.
The politics of health is a major reason why we continue to have scandals, deaths, and poorer public health than should be the case. All decisions on health, at local level, come down to a simple attitude: “What we have, we hold”.
There is a shining example of a better way. Cancer care has been greatly improved since it was reconfigured into centres of excellence a few years ago. That took an outsider — returned emigrant Prof Tom Keane — to implement. He came up against fierce opposition, but the government of the day knew that if he walked it would reflect appallingly on the administration. So they reluctantly let him at it, and rates of recovery and mortality have improved hugely as a result. The instinct to hold on for dear life to the local, less efficient facility has extenuating circumstances. There is lingering distrust of central government. There is deep-seated worry that the promise of better care further away will simply turn out to be inferior care further away. The removal of something that has “always” been there will inevitably generate short-term fear. And transport for areas that are particularly isolated is often ignored.
Then there’s the politics. The multi-seat system greatly heightens competition and rivalry. If one politician is willing to tell it like it is for the common good, there will always be another who sees irrational fear as an opportunity. It can’t all be blamed on the politicians. Certainly, precious few of them display any leadership in health, but it takes two to tango, and voters reaffirm them in their perception that pandering to fear will always trump leading from the front. In the meantime, people die; public health remains inferior; scandals await. That’s the Irish way of doing things. So when tragedies occur, and families express their grief and rage, a little reflection from society wouldn’t go astray. There is plenty of blame to go around.
Michael Clifford
