Relationship between State and institutions is not always healthy

FOR A number of days spread over a couple of years, I’ve had reason to be lying on a hospital bed staring at the wall opposite me. Nothing life-threatening involved, but there all the same. Try as I might, I can’t remember seeing any crucifixes or religious paintings on any of the walls I’ve had to stare at.

Does that mean they weren’t there? Probably not. I’m guessing it’s much more likely that they simply never registered in my addled old brain. I’m reasonably sure that if there had been a Buddha on the wall I’d have noticed it, but I stopped noticing the religious icons I was raised with many years ago, because they stopped having meaning in my life.

Which I guess is the reason I’ve been a bit perplexed by the public debate on a new recommendation that hospitals in particular should “be cognisant of the impact of (religious) décor on patients or service users and strive to ensure that their personal preferences in this regard are met to the greatest extent possible”.

It’s great radio fodder, that sort of thing. The older generation gets all huffy about the importance of tradition (“it’ll be the crib next!”), and the younger generation waxes on about the separation of Church and State. But nobody ever seems to say live and let live any more. If I wake up in a hospital bed, and find something on the wall that upsets me, it should be taken down. But if I’m the patient, and I’m not bothered, then nobody else should matter.

Lots of people, especially when they’re not feeling well, derive comfort from being surrounded by the trappings of religion. They should be respected, and the rest of us should mind our own business.

But I guess the other reason I’ve been a bit perplexed by the debate over all this is because the thing about organisations being cognisant about their décor (even the language is quaint) was the least important recommendation in a report that contains a lot of really important stuff.

The pity is that this minor recommendation, contained in a couple of paragraphs over page 50 and 51 of the report, has dominated such public discussion of the report.

Why does that matter? Because this is a report into the relationship between some of the more powerful and influential organisations in the country, and the State. The report has a less than elegant title (Report of the Independent Review Group established to examine the role of voluntary organisations in publicly funded health and personal social services), and it pulls its punches a bit too often, but it sheds a lot of light on a vitally important subject, that we all ought to be concerned about.

Within the health and social services sector in Ireland there are four different broad types of organisation delivering services. These services are intended to improve the quality of life of people who are frail or sick, who live with disabilities or mental health issues, or who have to cope with all the consequences of ageing. Tens of thousands of us, to a greater or lesser degree, depend on these services.

Some of them are provided directly by the State itself. Some are bought by the State from the private sector. And a huge proportion of these essential services is provided by the voluntary sector.

Except it’s not really the voluntary sector at all. It’s a sector that doesn’t, in the main, employ volunteers. It doesn’t give away its services free of charge. Although many, probably most, of the organisations in that sector are registered charities, they are largely, almost exclusively, funded by the State.

In the context of health, there are two types of these organisations. One is called Section 38, the other Section 39 (these are sections of the act that set up the HSE). Section 38 organisations are more or less 100% funded by the State to do key things. Section 39 organisations are partly funded by the State, and have to raise additional money themselves.

There’s actually only about 40 or so Section 38 organisations, while there are more than 2,000 Section 39 organisations. But the 40 Section 38s are immense.

These 40 organisations — most of them hospitals — employ 40,000 people. In the last full year for which figures are available, they got almost €2.5bn in State funding. They own immense reserves of land, property and other assets.

Although funded by the State, they are run by independent boards. Mind you, the boards are independent only of the State — many of them are appointed by religious organisations. Many of them are essentially owned by religious organisations.

These hugely significant entities include the Mater and St Vincent’s Hospitals in Dublin, the Mercy Hospital in Cork, and a number of others. Ireland depends on them — if we ever had to replace them, the cost would bankrupt us. Thousands of lives every year are saved or improved behind the walls of these hospitals.

But that doesn’t mean that the relationship between the institutions and the State is always a heathy one. Nearly every year there is an issue of governance. The most recent annual report of the HSE, for instance, makes the point that “Compliance statements submitted by 35 Section 38 agencies in relation to the financial year 2016 indicate gaps in governance arrangements such as public sector pay policy and, in particular procurement”.

In many ways, the relationship is shrouded in mystery. If you look at the larger service providers in the disability area (some are Section 38, many are Section 39), it very quickly becomes impossible to figure out who owns what. Try deciphering the accounts that are published each year by the faith-based organisations that own and operate many of these services, and I guarantee that you’ll very quickly need to lie down in a darkened room.

That wouldn’t matter, I guess, if you and I weren’t paying for these services, and it certainly wouldn’t matter if the services were as good as they should be, But there is a huge lack of transparency around all that, and may of the services range from poor to middling.

One of the key recommendations of the report is that we need to move away from the traditional models of funding these arrangements, and start thinking about commissioning services instead, on a properly funded basis.

If we’re going to have a discussion, wouldn’t it make more sense to discuss this idea, rather than the idea of crucifixes on bedroom walls? There is a vast range of personal and social services, almost all of which could be delivered better, faster, more responsively, and in a more accountable way than they are now.

If that’s to happen, the funding relationship has to change. If you have a 40-year long relationship, where you pay the money and they provide the same services they always have, where’s the incentive to improve? And that would be typical of many of the funding arrangements in Ireland.

If we want services to improve, it’s time to tell the service providers that the power relationship has to shift a bit.

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