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Decades of unscrambling the curate’s egg

Dr Garrett FitzGerald proposes three key requirements should the HSE and Department of Health ever get real about reorganising the ‘deranged, riotous, harum-scarum atmosphere of 2018 HSE-land’

The latest ‘scandal’ in the health service will give politicians and media dwellers the usual opportunities to draw attention to them, as is always the case. Sentences, marginally short of the guill­otine, are being passed on the airwaves before the trial takes place. Radical therapy is being urged before the results of the biopsy come in. The Health Service Executive (HSE) head is asked to offer up his head. It has been asked for before but not as vehemently. Paper never refused ink.

Dr Garrett FitzGerald

There have been lots of previous ‘scandals’. Perhaps the biggest one of all is that, during the life-span to date of the HSE, many of our services have been grinding to a halt, becoming increasingly in­ accessible and have deteriorated in quality and humanity. Since the abolition of the health boards, decision-making has moved further away from the carer and the patient. There is a sense that there is no democratic or medical professional input.

The HSE is now a dictatorial cabal immune to outside views.

State of failure
And it is in a state of advanced failure. In somewhat of a curate’s egg; there are of course oases of excellence and islands of competence — like patches of viable myocardium between the infarcts. But there is something rotten at the heart of it all and it is steadily becoming more rotten. Our emergency departments become ever more crowded and inhumane, patients wait for ridiculous periods in pain and distress for consultations, diagnostic tests, treatments, operations, and admission to hospital when seriously ill. Many are truly frightened by the prospect of a visit to our hospitals. Some just will not go and would prefer to take their chances.

Outside of the general hospital services, the mental health scenario — particularly for young people — is chaotic and, at best, negligent. At-home services, respite, long-term non-institutional and institutional cares are hopelessly inadequate and a ‘lottery’.

Primary care is in disarray with a shortage of facilities, personnel and doctors.

Further deterioration
In much of the services, the prospect of further deterioration is inevitable, given continuation of current approaches. Healthcare professionals do not want to continue working in the HSE. There is a severe problem with recruitment of all grades. One might particularly mention nurses, doctors-in-training, family doctors and consultants because they are the key people around whom the service should be built.

Yet we cannot recruit in any of these grades. This has never ever happened before. Bottom line is that they do not wish to work in the deranged, riotous, harum-­scarum atmosphere of 2018 HSE-land.

In parallel with the deterioration — and feeding in to it — there has been a population increase of 15-20 per cent in recent decades, a substantial rise in life expectancy, a big population of elderly ‘survivors’ with multiple health needs, a flood of effective medical advances and expertise, a changing demographic with urban-rural population realignment and family structure, as well as burgeoning expectations.

Reorganisation
While all of this expansion is going on there has been a contraction in many services. Standing still — or less! — should not have been an option, but that is what has happened. Our health service failed to take into account the changing demographics. We are all paying the price now. Sadly we will pay it for decades to come.
If the HSE/Department of Health were in the real unsheltered world where most exist, they would have folded up their tents long ago and gotten off the potty.

Reorganisation, an unenviable but essential task, has three requirements: Money, planning and expertise — all three underpinned by honesty.

Floundering system
The honesty bit means admitting that the system is floundering and ready for sinking.

Honesty means admitting that a reasonable system would cost a lot more and the money has to be raised by the citizen. Honesty means admitting that the people and organisations running our health services are not up to the task and well-meaning amateurs should no longer be in charge.

Honesty also means admitt­ing that we don’t know it all and we need help from wherever we can get it — ‘we’ applies particularly to our politicians and healthcare administration.

Honesty means telling the citizenry the truth. We cannot continue with the three-card trick and the flimflam tactics so beloved of our masters.

The ‘X’ factor
Planning of services is based on the minister of the day announcing that ‘x’ is the budget for the year.

The plan which emerges will always be predicated on the ‘x’ factor to the exclusion of almost every other consideration.

This is nonsensical and no business could survive on such a plan: Like telling the coffee shop owner that he may not install a second coffee table although the queue of paying customers stretches down the street.

The plan should instead be to estimate (with expertise) the needs, now and into the future, from these then deciding what requires to be done in order to reasonably, decently and humanely see to these needs in a competent way.

Honesty requires saying it like it is to the people and to the politicians. The ball is then in their court.
Until this happens, we are hopelessly snookered.

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