GERARD HOWLIN: Vested interests within the health system adding to pain of 'living on the list'

Sharon and her daughter Megan, 13, who is suffering worsening scoliosis on 'Living on the List'.
Sharon and her daughter Megan, 13, who is suffering worsening scoliosis on 'Living on the List'.

Vested interests within the system benefit from work practices that are costly in cash, and contribute to keeping people ‘living on the list’ in pain, writes Gerard Howlin.

PAIN is not a systems issue. It’s highly personal. If not relieved, it may suddenly — or progressively — close in the frontiers on your life. Monday night’s RTÉ Investigates: Living on the List was harrowing viewing. There were moments watching it when I winced at the description of what people were going through. But that momentary, involuntary discomfort pales compared to the actual pain of others.

One doctor interviewed, suggested thinking about having toothache 24/7 for years on end, to try to imagine what some people ‘living on the list’ go through. Even if you can imagine the physical pain, what of the psychological or social consequences of seriously ill patients, living for months, even years, in pain and with worsening conditions?

One woman referring to all the tablets she was on, admitted she is tempted at times, to overdose. Pain is a life-altering condition, and the physical symptoms are only the most obvious. Like going to funerals, I have a notion we Irish are good at visiting people in hospital. It’s a ritual and an outing, and hopefully a morale boost for the patient. But people ‘living on the list’ are not in hospital; that’s the point. They live at home, without the panoply of being a patient. They get on with life as best they can.

These are lives that socially are deeply circumscribed as well as being physically discomforted. Those same lives simultaneously circumscribe others, who undertake their care. Perhaps they are the lucky ones. What of people, in pain, ‘living on the list’ who do not have a close network, or partner to fall back on?

Off camera and out of the programme on Monday night, I had a sense of many who do not have advocates or carers, and who maybe are not best placed to advocate for themselves, with the system that leaves them stranded. Beyond the physical, is the fact that their social participation, depends on their health. Now their isolation is a double-down. They are sick at home, and there is nobody else at home either.

One ill woman on the programme wondered, wistfully, if her husband might be tired of looking at her; but she need not have. He wasn’t. But there are others who have nobody to look at, and nobody really committed to looking after them. Being outliers and not having many visitors literally or metaphorically, their lives depend on participation. Not to think of a little boy or a young teenage girl, who can’t do all the things their friends do. It’s hard to make sense of that at any age, but especially a very young one. There are layers so deep to this; the highly personal consequences of a failing system.

But if pain is highly personal, systems are impervious. They may succeed, or they can fail, but there is nothing personal. Our health system is the largest and the most complex organisation in the State, by far. Nothing remotely compares in any private business, and ultimately it is not a business. The State’s interest is primarily a social one. It’s big business because of the cost, not least to the State.

Vested interests within the health system adding to pain of 'living on the list'

On health spending, however, we do magnificently well. In an analysis by Michael Hennigan on the excellent, we see that Ireland has the second-highest health spending ratio in OECD area which comprises of 34 mainly developed countries.

In 2014, Ireland’s public spending on health, including current and capital, was, at almost 20%, the highest in the EU. Depending on how you measure, and if you choose to measure against Gross National Income (GNI) you can postulate that we have overtaken the Dutch, with the best European system, on health spending. Now statistics are devilishly ticklish.

Our particular economic model is a chamber of smoke and mirrors when it comes to measurements. But, however you measure it, and it has been measured several ways, we spend a lot. And especially, we spend a lot for what we get.

There is a real lack of capacity, including hospital beds and doctors. Addressing either requires even further resources. But though this is readily repeated, there is no consequent recipe for savings. Of course not. Vested interests within the system benefit from work practices that are costly in cash, and contribute to keeping people ‘living on the list’ in pain.

That is not to count the collateral damage to areas outside the hospital system — areas such mental health, which is beggared to support a system configured to benefit its operatives — not the patients who are its objects.

Individually overworked, stressed doctors and nurses will resent the accusation. They have a point. If you become their patient, you have a very good chance of meeting a committed clinician. That doesn’t detract from the disquieting truth, that as a series of collective vested interests, our health system is hostage to and exploited by its operators. In turn, working in sometimes stressful situations, those same people lash out at what they feel they have no responsibility for.

A basic fact, before we talk of the work practices of porters or radiologists, is that the 80:20 ratio of public to private patients in public hospital is routinely ignored. There is no effective consequence for any consultant who flouts it. If hospital management is inadequate and sometimes it is, its powerlessness is the bigger problem. That ineffectiveness is abject in the face of consultants, who in hospitals, are too big to fail.

They are certainly too scarce to replace. And all the while, people ‘living on the list’ are in pain.

The truth, which neither hospital consultants nor politicians will face up to, is that private medicine has no place in public hospitals. Were that to be applied, there would instantly be a cash crisis and a rush of white coats towards the gate. But, that would only be the beginning of it. The real backlash would come from the electorate. Nearly half the population have private health insurance. Among those who vote, they are much better represented. There would be political meltdown, as middle Ireland marched over the bodies of the afflicted, to reassert its right to subsidised privilege. You should never mistake public outrage with the status quo with the will to change it.

The policy corollary of this unpleasant but fundamental truth, namely the provision of additional capacity by the co-location of private hospitals with public ones, has never been implemented. So now we enjoy the worst of both worlds. Privateering empires persist in public hospitals. Staunch pillars of the system as powerful collectives, but as individuals, in the main genuine carers, our medics berate a system they are the bastions of. But that’s just the system; it’s not personal. As for those on the list; we feel your pain.

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Nearly 560,000 waiting for treatmentNearly 560,000 waiting for treatment


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