Sláintecare demonstrates a fondness for Orwellian, Animal Farm type thinking

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Sláintecare resignations, what was that all about? I attempted, but failed, to make sense of what was happening.  It seemed as if the main characters in that drama had remembered Heaney and when faced with having to say something, took his advice and said nothing.

Denis Doherty
Denis Doherty

The Sláintecare report was published in 2017 and proposed the most radical reform of healthcare ever undertaken in Ireland. It met with the approval of all of the main political parties. Four years on, little has happened to advance the key recommendations contained in the report. In fact, many developments have taken place that are the direct opposite of what the Sláintecare report recommended.

Sláintecare recommended that everybody be given timely access to all health and social care, free at the point of delivery and based entirely on clinical need. Employing that approach, Ireland would become either the envy of the developed world or a latter day version of a failed Soviet republic!

Sláintecare demonstrates a fondness for Orwellian, Animal Farm type thinking. For example, public health care = good, private healthcare = bad: integrate = good, entangle = bad. The use of the word disentangle in a derogatory sense demonstrates a remarkable disregard for the role played by private and voluntary hospitals as well as charitable and voluntary organisations in the development of our health services.

The use of the word disentangle in a derogatory sense demonstrates a remarkable disregard for the role played by private and voluntary hospitals as well as charitable and voluntary organisations in the development of our health services.

During Covid 19, our health services performed as well as the best internationally. Great credit for that is attributable to the calibre of our health care professionals. There exists a growing shortage of consultants, general practitioners and healthcare professionals. The growing number of healthcare professionals choosing to engage in private practice only compounds that problem. Then there is the risk that it may prove more difficult in future to recruit health professionals in the numbers and of the calibre we have been able to count on up until recently. A ham-fisted approach to healthcare reform needs to be avoided. Covid ought to have taught us that in order to attract and retain the best healthcare staff we can afford, we need to offer challenging and rewarding employment. The mix of public and private hospitals here has been an advantage in dealing with the Covid pandemic. That experience ought to be assessed and used to inform future relationships.

Some health services just don’t lend themselves to rationing.  Surgical treatment for children with scoliosis is a case in point. In keeping with Sláintecare report advice, best outcomes are achieved through timely interventions based on clinical need. Four years on, new funding signposted in November 2021, while welcome, is predicated on a finite number of patients being treated rather than meeting the established need. If Sláintecare is to be taken seriously, this would be a good place to start.

Palliative care is another good example of a service that ought not to have to cope with waiting lists or rationing. Palliative care is delivered free at the point of delivery. The problem is that in some regions specialist inpatient palliative care facilities have not been developed. The physical infrastructure needed to deliver a modern palliative care service was set out more than a decade ago and significant progress has been made in most areas. An exception is the Midlands region of Laois, Offaly, Longford and Westmeath, a disparate collection of counties without a history of doing things jointly. It is now the only region that does not have a Level 3 hospice or firm plans for one. The formula used elsewhere is that local communities raise the capital cost of the unit and the State then provides the ongoing revenue costs. Fundraising commenced in the Midlands two years ago and a figure of €2 million is expected to be realised soon. The problem is that, Covid blamed, building inflation amounts to more than the €2 million funds raised. The people of the Midlands require inpatient palliative care services to the same extent as people elsewhere but custom and practice trumps Sláintecare advice of universal entitlement based entirely on clinical need. The people of the Midlands do not have access, within their region, to specialist inpatient palliative care services or the very valuable outreach services provided by specialist units to patients in the community.

Sláintecare is surrounded by icebergs and needs to wait and hope for the best while the ice is in control and then proceed to calmer waters while a course of safer travel is plotted.

Sláintecare stresses the benefits of delivering community services in patients’ homes or locally. Time was when what was then termed home help was delivered by local parish based organisations that received grants from their local health boards. The rates of pay were modest but all of the funds provided were used to pay those who delivered the services. Homecare is now a fast growing service industry, involving keen competition and costly television advertising. Critics argue that contact time allocations often don’t match users needs and that too much of the time of service givers is taken up travelling between short visits to service users. It is in the interest of caregivers and their clients that these services should meet quality and governance standards at least equivalent to those provided in residential settings. ‘Homecare packages’ is a term used to describe what is offered to individuals in need of care at home. It is the polar opposite to the needs based approach advocated in Sláintecare four years ago.

Nursing home care is now dominated by the private sector. Over time, the proportion of people over 65 years of age in residential care has remained steady at about 5%. What has changed is that public sector provision has declined and been replaced by expansion of the private sector which is also expanding to meet the growing number of older people requiring residential care. Nursing home groups are acquiring smaller stand-alone nursing homes. They in turn are being acquired by international nursing home groups. Just like hotels, many existing nursing homes are being expanded and some new ones are catering for numbers on a par with the numbers catered for by the much criticised County Homes of old. Those trends have accelerated since the publication of Sláintecare and no one shouted stop. Private nursing homes are not going to be integrated into the public health care offering and their services will never be free at the point of delivery as envisaged by Sláintecare.

The failure to appoint regional entities appeared to have influenced Slaintecare resignation decisions recently.  Understandably, in my view, regional entities merited only a few lines in the Sláintecare report. To prioritise that matter at this stage would put it in the rearranging of the deckchairs on the Titanic category, in my opinion. The Titanic had a well-charted course of travel but was unlucky to strike an iceberg. Sláintecare is surrounded by icebergs and needs to wait and hope for the best while the ice is in control and then proceed to calmer waters while a course of safer travel is plotted.