independent

Monday 21 April 2014

Unity and honest dialogue is only way to resolve crisis

Government must lose its contractual mindet and realise that medicine is a vocation, writes Ray Kinsella

It took €15m – not provided for in the Budget –and a strike to resolve the Non-Consultant Hospital Doctors (NCHD) work stoppage. It highlighted yet again the chronic failure of successive governments to resolve the medical manpower crisis in our public hospitals.

Exactly 10 years ago the Hanly Report pointed out that to deal with the impact of the European Work Time Directive (EWTD) on the hours worked by NCHDs would require 3,100 consultants by 2009 and 3,600 by 2013.

Ten years on, the NCHDs felt impelled to take industrial action, the number of consultant posts has collapsed, and the process of appointing a consultant takes years. The level of stress across the professions is unlike anything we have seen.

This isn't just bad – this stasis in medical manpower policy is a national disgrace. It is sapping the morale of the medical and nursing professions. It has eroded the capacity of the health system to deal with existing and future challenges.

It may be that dealing with the issues is beyond the capacity of the system to manage. But there may be deeper reasons – reasons that are rooted in the adversarial mind-set that has been a feature of government/HSE interaction towards the medical and nursing professions for far too long.

Nurses and midwives are professions whose members arrive early and leave late. The Government has left them coping with massive cuts in already low salaries while simultaneously being made responsible for equally massive pressures in the public system, including the fact that they are the de facto transmission belt for interminable "reforms".

As for medical students who are graduating this year, the priority for many of them is to make sure they have passed eligibility exams for the US or Canada or Australia – and to get their visas. The pressures on GPs now and into the future are huge, while they are left flailing in the exponentially increasing acronym-based 'standards' industry.

Then there are the consultants. The Government has moved to trust-based hospital networks. New structures mean nothing unless you can attract, and retain, high calibre, motivated consultants.

A major issue here is in the implosion of consultant salaries, and therefore the capacity to retain in Ireland (let alone in the public system) existing and future consultant leaders. A second issue is the meltdown in Ireland's attractiveness for highly mobile consultants working abroad.

At present, engagement by consultants with the public at policy level is refracted through contractual and political filters. It is skewed and not infrequently caricatured. This means, for example, that the IHCA's pre-Budget submission – which is evidenced-based and insightful – counts for little. The Troika and the State are not listening

There is the most compelling evidence that austerity has a highly negative impact on the health systems of precisely those economies that are already impacted by long-term unemployment and poverty. The lack of alignment between the mind-set of government, based on power, and the mindset of professions, trained to serve, is at the heart of this stasis.

The mindset of government is contractual, it's about terms and conditions. Hours. Rosters. Limitations on advocacy. It takes no account of what many members of the nursing and professions, including consultants, actually do over and above that for which they are contracted.

This may be legitimate for businesses. What is not legitimate is for one party to negotiations to adopt a purely contractual mindset while simultaneously demanding that the other party approach negotiations from an essentially vocational perspective.

It's worse than that, of course. No company – or government – could possibly function where so many key appointments are left unfilled, where the manpower policies are so divisive, budgetary policies so flawed – and where the risks arising from this dysfunctionality are so pervasive.

A significant loss of "welfare", in the economic jargon, which translates into fewer theatre slots and overcrowded clinics and a catastrophic loss of morale and motivation are the consequences.

This is the mindset of our political orthodoxy. What it means is that just as the Government socialised the costs of the banking crisis on the wider economy, so too the deeply flawed policies of "adjustment" in the health system are being imposed on those who trained to provide care – and, by extension, those seeking access to care.

So, how to transcend this? The credibility of a profession – including its credibility in negotiations and in advocacy – is inextricably tied up with its sense of moral purpose. The various parties can work together much more closely than they do at present. It is this lack of unity across all of the different domains that has left each of them wide open to a "divide and conquer" contractualist mindset. It is this fragmentation that constrains their joint advocacy of those awaiting surgery, those on waiting lists and on trolleys.

There is little point in the professions looking to the Government or the State to empower them to do all that they were trained to do, all that they can do, all that they want to do. The State can't give to a vocational profession rooted in the Hippocratic Oath what it doesn't understand, much less have in its own self to give.

However valid criticisms of the policy mindset on medical manpower, they will count for little in terms of outcomes until the professions together restate their commitment to values with which the patient and their families and society can identify.

This and only this will provide the platform for them to communicate to a listening audience the facts and the truth; and the possibilities for re-creating the kind of health service, imagined by the late Maurice Neligan – one which reflects the fierce integrity of medicine, as a moral enterprise before anything else. This example of unity may be the catalyst for a dialogue with that new political mindset – and for wider change.

Professor Ray Kinsella is editor of 'Acute Healthcare in Ireland'.

Sunday Independent

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