Bureaucracies and privatised healthcare will not solve the crisis in the health service, writes Madeline Spiers
As winter approaches we are yet again facing the ritual accident and emergency crisis, which will be very severe this time as there has been overcrowding all through the summer.
However it must be remembered that this is only the most public manifestation of the ills facing our health service and it must not be allowed to minimise the difficulties affecting care of the elderly, community or other services, or prevent a public debate on the increasing privatisation of this country's health services. These difficulties continue to deepen as the health reform programme, hailed as a solution to many problems, has resulted only in even greater levels of inertia and indecision.
The Irish Nurses' Organisation's experience of the health service reforms has been that instead of recognising, acknowledging and dealing with these fundamental problems, all of the time has been spent upon protecting and further enhancing management bureaucracies. There has been no attempt yet to include clinicians in the Health Service Executive's (HSE) corporate management structures and, in fact, every effort has been made to avoid doing so. This basic flaw and failing must be addressed if the needs of the patient are to be put first, rather than the needs of the bureaucrats.
A graphic example of this is the scandalous waste of money arising from the fundamentally flawed payroll system (PPARs). Imagine what a difference €150 million would have made to so many patients and frontline staff to ease the overcrowding in A&E and to the provision of care, with dignity, to the elderly.
Nurses, midwives and patients know that there are severe staff shortages in our hospital and community systems. This places every nurse and midwife under severe pressure due to the number of patients that they are being asked to care for at any one time. I have spoken to nurses and midwives, in all healthcare settings, and the key message they keep repeating is that they do not have the time to give the quality of care they would like to. No one in management should seek to justify or defend the many examples of one nurse looking after up to 40 elderly patients for up to 16 hours per day or one public health nurse seeking to meet the needs of a catchment area of 5,000 people.
The workload carried by nurses and midwives has become more complex, often reaching unbearable proportions, putting both patients and these frontline professionals at risk. Recent large-scale international research found that the optimum average workload for a nurse was four patients and that increasing the workload to six resulted in patients being 14 per cent more likely to die within 30 days of admission, while a workload of eight patients versus four was associated with a 31 per cent increase in mortality (Aiken et. al. 2002).
Nurse/patient ratios in Ireland have been determined in an ad-hoc fashion, with nurses not being allowed input into the process despite the overwhelming international evidence that patient outcomes are better when nurses/midwives have control over their workloads.
The difficulties arising from overcrowding, such as increased cross-infection, loss of privacy and dignity, increased waiting times for treatment, all negatively impact upon patient care. It is trite to suggest, as the Minister has, that "you do not need money to wash your hands". The constant objective, in recent years, has been developing management systems and not enhanced patient care. There has been no support for the nurse or midwife who was concerned about the lowering of standards of care.
In recent weeks, we have seen a discernible shift by the Government to saying that the provision of health services, in the future, should be undertaken by the private sector. This, apparently, will be actively encouraged through the use of tax incentives for those who wish to build and run nursing homes and small private hospitals. This shift has taken place without any public debate and without any evidence suggesting that it will address the fundamental and chronic problems facing our health services. I am not alone in saying that this policy shift is deeply flawed and will lead to an imbalance in our health services, a return to the old dispensary system, and further entrench the existence of a two-tiered system where those who can afford it will undoubtedly access care more quickly and in better physical environments.
So, we now have a situation where we have a health strategy that the Government appears unwilling to fund and a previously unheralded decision to invite the profit-seeking private sector to provide, without proper regulation, key services. Is it any wonder that, against this background, we have a continuing exodus of Irish nurses abroad to escape a system under severe pressure from unprecedented demand and weighed down by layers of lay managers, with the main response being to enhance the private healthcare sector?
In the middle of all of this we have Irish citizens on trolleys for days, elderly dependent people not receiving the quality of care they deserve and the marginalised in the community not accessing the required services. The reform programme must allow nurses, midwives and other clinicians manage the services they deliver.
That was what was promised, not bureaucracies and privatised healthcare. It is now time to deliver in the interests of the patient - the person who really matters.
• Madeline Spiers is president of the Irish Nurses' Organisation