Review: Marie O’Connor – Emergency: Irish Hospitals in Chaos (2007)
€14.99, Gillmacmillan, Dublin
27 March 2008
The publication of Marie O’Connor’s Emergency: Irish Hospitals in Chaos comes at a time when the issue of the health service is assuming a growing importance in the national political agenda. Not a week goes by without the exposure of some abuse or failing within the system. There is a growing consciousness that something is fundamentally wrong with the health service and that there needs to be urgent action to put it right.
It is these two fundamental questions of What is wrong? and What needs to be done? that O’Connor attempts to address in Emergency. For this task she is able to draw on her experience as a health journalist of twenty years and as an activist with the Health Services Action Group. The introduction contrasts the apparent wealth of Ireland with the “primitive conditions” (p.viii) that prevail in so many public hospitals. She also highlights the paradox of more and more money being poured into a system that “seems to stagger from one crisis to another, with no visible improvement” (p.vii). On the basis of these contradictions O’Connor describes the Irish health service as “dysfunctional”. In the first part of her book she explores the causes of this, what she calls the “threads of dysfunction” (pxi).
In a brief opening chapter entitled “Medical Fiefdoms”, and as a preview of a theme that is taken up in more detail later, O’Connor gives an overview of the development of the modern health service in Ireland. She traces this to the granting of a royal charter to the College of Physicians in 1667, which gave it a monopoly over the practice of herbalism in Dublin. A second charter in 1692 gave the College the power to grant licenses in medicine and midwifery. In 1784, the Royal College of Surgeons was established. The first attempt to regulate medicine in Ireland came in 1858 with the Medical Regulation Act. This empowered the General Medical Council to keep a register of qualified medical practitioners. (p.5) The first hospitals in Ireland were provided by charities and religious institutions. Public hospitals were slow to develop. They appeared in their most basic form as part of the workhouse system set up under the 1838 Poor Relief Act. Though the infirmaries attached to workhouses provided an exceedingly basic form of medical care, they were the main source of hospital care for most rural areas in Ireland. (p.6)
In the next chapter of Emergency, which is entitled “World Class Chaos”, O’Connor gives us an insight into the state of Irish hospitals. This chapter opens with a number of case studies of the experiences of A&E patients. These include a 66 year old stroke victim who had to spend two days on a trolley before getting a bed at the A&E department of Dublin’s Mater Hospital; a woman with a clot on her lung who had to wait eight days on a trolley in the casualty unit of Tallaght Hospital; and an elderly woman who died of a brain haemorrhage while on a trolley in the Mater Hospital.(pp. 12-15) Hospital waiting lists are so bad that some patients are driven to go to a casualty unit in the hope of getting treatment. O’Connor claims that long waiting lists are a result of the health service’s “entrenched two teir system”(p.15) in which public patients may wait years for treatment which private patients receive within weeks in the same publicly funded hospital. She also claims that official waiting lists in Ireland do not show the full extent of the problem. For example, being referred by a GP does not mean you will actually get an appointment as an outpatient. Also, the time spent waiting for a specialist out patient appointment does not count as waiting time. Only time spent after seeing a consultant is counted. (p.17) Another major problem in Irish hospitals is cancelled appointments. Appointments are cancelled because hospitals do not have beds to accommodate patients booked for surgery. There were 20,000 cancelled appointments in 2004 and 22,000 in 2005. (p17) One emergency consultant has described the situation as being “worse that Baghdad was in the 1980’s.”(p.19) It is estimated that overcrowding in Dublin A& E departments could be leading to over a 100 deaths a year.(p.20) The response of the Government to this crisis has been to offer piecemeal solutions. In June 2005, the HSE announced a €63 investment pan for A&E services (p.21), but subsequently all monies were frozen pending the result of a value for money audit.(p.22) In May 2006 the Government unveiled a new carrot and stick approach, with casualty units not reaching new A&E targets being docked two percent of their annual budgets. Alongside this, up to 100 additional consultant posts were to be funded in high performing A&E units. (p.22)
O’Connor contends that the fundamental reason for waiting lists, cancelled appointments and overcrowding is that there are not enough public hospital beds to go around. (p.22) While it is true that spending on health has increased considerably over the past decade, the real increase is less than it appears when price and wage hikes are taken into a account. Irish expenditure on health per head is less that 90 per cent of the EU average; in the period 1970 – 96 it was only 63 per cent of the EU average. (p.24) The difficulties hospitals are experiencing are not just a result of current polices but of a long legacy of under funding. O’Connor also highlights how increased expenditure on health has not been matched by outcomes. For example, from 1997 to 2004 the funding of acute hospitals rose by 72 per cent, yet the number of patients treated by doctors increased by only 44 per cent. Bureaucratic targets have also perverted medical practice, with operations being cancelled because patients were occupying beds on the day ward in order to prevent trolley waits in A&E. (p.26) On top of this the Government has failed to deliver on its minimal commitments on health. For example, the 2002 Programme for Government promised 3,000 new acute beds, but by 2005 only 419 new public acute beds had been installed. (p.27)
O’Connor argues that many of the inadequacies and shortages within the health service are a result of a shortage of medical staff. For example, Ireland is still short of hospital specialists. Its doctor – population ratio is only 22 doctors to 10,000, far below the EU average of 33:10,000. Cutbacks in nurse training have also led to shortages. The growth in employment in the health service has been on the non-medical side. Between 1997 and 2001, there was a 66 per cent increase in health management and admin staff, three times the rise in nursing, medal and dental staff. Government policy on public sector employment has also produced distortions, with periodic freezes on public sector employment resulting in hospitals employing private agency staff at double the cost. (p.28)
In chapter three, The Killing Wards, O’Connor examines the growing problem of hospital infections. She claims that a lack of isolation facilities and shortage of isolation control staff employed in Irish hospitals is making viruses difficult to control. (p.32) This is compounded by the fairly high use of antibiotics. There is also a reluctance to admit the extent of hospital infections, with the HSE refusing to release information on MRSA deaths. What we do know is that MRSA blood poisoning levels in Ireland are among the highest in Europe. O’Connor argues that the proliferation of MRSA could have been avoided if the Government had the political will to do so. (p35) Instead it has allowed serous discrepancies in infection control to arise. The most obvious one is the lack of a national system of surveillance. (p36) Also, hospitals are dirty partly because the responsibility for cleaning has been outsourced to private cleaning firms. (p.37) Poor patient- nurse relations have contributed to the rise of hospital bugs. O’Connor points to the lack of infrastructure as key factor in the rise of hospital infections, drawing a direct link between the non-isolation of MRSA patients and the Government’s refusal to provide more public beds. (p.38) This has resulted in Irish bed occupancy rates being among the highest in the developed world. (p.39)
In chapter four, Principalities and Politburos, Marie O’Connor examines the defects in the organisation of the Irish health service. She uses the term “dysfunctional work places” (p.45) to describe hospitals which are the site of daily power struggle between medical, nursing and administrative hierarchies. (p.47) For O’Connor this is one of the consequences of growing bureaucracy within the health service, which from 1980 to 1993 saw the number of administrators increase by 32 per cent while the number pf medical staff fell. (p.51) Another tendency has been the centralisation of the management of health services. This was advanced most in the 2004 Health Act, which abolished regional health boards and created the Health Service Executive (HSE) to control and manage the delivery of all health and personal care services. O’Connor describes the HSE as a “bureaucratic monster” that “increasingly behaves like a corporation.”(p.51)
In chapter five, The Last Waltz, the author highlights the staggering number of people who are killed or injured in hospitals. It is estimated that 14,000 people are injured or die as a result of medical treatment every year in Irish hospitals. Death rates in or around the time of birth are among the worst in the EU. There is a very high still birth rate. (p.55) The next chapter, Heart of Darkness, focuses on two of the of the most notorious examples of injures to patient as a result of treatment. The first is the practice of symphysiotomy. This is a hazardous procedure that is carried out in the final months of pregnancy in which a women’s pelvis is widened by cutting through the cartilage that binds the pubic bones together. This procedure is usually carried out in cases of difficult labour in countries where Caesarean section is not an option. Yet hundreds of symphysiotomies were done in Irish hospitals from the 1940’s until the 1980s, leaving many women permanently disabled. What lay behind the widespread use of this practice was religious dogma; what O’Connor describes as the “triumph of theology over reason.”(p.66) According to Catholic belief Caesarean births encouraged sterilisation, contraception and abortion.(p.67) For Catholic doctors, symphysiotomy was therefore a “pre-emptive strike making repeat caesareans redundant and preserving the moral fibre of the nation.”(p.68) Despite up to five hundred women across the state being mutilated in this way, there has been no investigation, inquiry or compensation. (p.70) The second notorious case of injury to patients highlighted by O’Connor are the unnecessary hysterectomies carried out at Our Lady of Lourdes Hospital in Drogheda. Here the number of hysterectomies was twenty times the average. This abhorrent practice went unquestioned for a quarter of a century. (p.75) Most of these operations were performed by Catholic doctor, Michael Neary. Despite the evidence of malpractice at Our Lady of Lourdes, a panel of obstetricians exonerated Neary, and two reviews cleared his caesarean hysterectomy practice. (p.76) These cases inform a general critique of the medical profession that runs through Emergency, that it has an anti-woman basis and that it is largely unaccountable. O’Connor makes this critique much more explicit in the next section of the book, Empire Building, that examines the Irish medical profession.
Chapter seven, High Kings without opposition, traces the development of the health service since the creation of the southern state. According to O’Connor, the development of a public health service was hampered by the influence of Catholic Church as well as by free market thinking. (p.31) In the 1930’s, hospitals were funded through a lottery set up by the McGrath family known as the Hospitals Sweepstake. The overriding aim of the Church was to ensure that Ireland’s medical services reflected Catholic teaching. Medical education was given over to private trainers, such as the Royal Colleges, who exerted enormous influence over hospital services. (p.82) In Ireland the medical profession has traditionally policed itself. The 1978 Medical Practitioners Act provided for the self-regulation of the profession through the Medical Council. This is reflected in the make up of the Council with twenty-one out of twenty five seats chosen by universities and the Royal Colleges. (p.86) The Catholic Church and medical professions fought the development of socialised maternity care in Ireland. They contributed to the defeat of health minister Noel Browne’s Mother and Child Scheme in 1947. A version of the Act was passed in 1952 but it was severely watered down, providing only six weeks of free care during pregnancy, labour and after birth. The new scheme also fragmented maternity services by separating care during pregnancy from care during labour and after birth. Today Irish women still have no continuity of care, and community midwifery services are almost unknown. (p.88)
The power of medical consultants over hospitals has been underpinned by the Government gifting them public beds in public hospitals for their private practice. Taxpayers are forced to subsidise private medicine, footing over 40 per cent of the cost of the for profit beds. O’Connor describers this public-private mix as the “worm that is eating into the heart of the dysfunctional system we see today.”(p.89) Consultants also exercised power through the Hospitals’ Council. Created by the 1970 Heath Act, this body, which was made up of top consultants, controlled senior medical appointments. Though abolished in 2005, its influence lingers on as the 2004 Health Act obliges the HSE to consult with the Royal Colleges on all issues formerly dealt with by the Council. (p.91) For O’Connor, the Royal College of Surgeons typifies the worst of the public-private mix within the health service. As a medical trainer this body is a leading force in the health system. But its influence does not stop there. It is also heavily involved in the business and property sectors. Designated in law as a chartable body, the College has an annual turnover of €91 million on which it pays no tax. The Colleges “Court of Patrons” includes some of the biggest names in business and property in Ireland. (p.92)
Marie O’Connor goes on to examine the consultants’ contact. Drawn up in 1981 this covers all medical consultants working in the public sector. She claims that it gives “consultants unlimited powers and privileges without any enforceable duties or obligations.”(p.94) It also promotes private medicine by giving doctors the legal right to an unlimited private practice. While doctors are paid substantial salaries by the state they are under no formal obligation to devote even an hour a week to their public patients. In some hospitals, private practice accounts for 50 per cent of all activity.(p.96) O’Connor cites the threatened “strike” by consultants in 2004 as an example of the lengths they are prepared to go to defend their privileges. This arose from a dispute between the Government and the Irish Hospital Consultants Association (INCA) over the state clinical indemnity scheme. Under the new scheme proposed by the Government off site private practice would not have been covered. (p.98) Faced with a revolt by consultants the Government capitulated to the IHCA’s demands and agreed that the taxpayer would foot the insurance bill for work done by publicly employed consultants in private hospitals and clinics.
O’Connor claims that the tendency for doctors to have control over managing and delivering health services has become ingrained. This has created a situation in which health has become increasingly identified with the medical profession. O’Connor also contends that patriarchy within the medical professions has “ensured a continued, unbroken line of male power.”(p.103) For her all this represents a “triumph of organised medicine over the public interest.”(p.104) The democratic element of the health system has been steadily eroded in this process, reaching its height in the 2004 Health Act which stripped the system of all vestiges of democracy. This formalised the transfer of power from elected representatives to bureaucrats, and the shift from regional to centralised management. The Act also restricted complaints by patients. There is no longer any legal obligation on hospitals to review complaints from patients relating to their care. (p.104)
The author links the process of centralisation to increasing specialisation. Specialist services are more expensive, requiring special facilities, critical volumes and larger units – all pressures towards centralisation. The consequence of specialisation and centralisation has been the closure of smaller hospitals. The problem is that large centralised hospitals are impossible to manage well. (p.125) Centralisation is also a policy that disadvantages the less well off, for example people having to pay higher transport costs to make hospital visits.(p.126) O’Connor cites the Hanley Report on accrue services as the epitome of the drive towards centralisation. Under its proposals “smaller casualty units were to be sacrificed on the altar of emergency medicine.”(p.130) It proposed to strip up to twenty three hospitals of their emergency and maternity services. This meant cutting 250 beds in each region, more than 3,000 nationally, and cutting the number of maternity wards by up to half. (p.133) One of the obvious beneficiaries of this process would be the building industry with vast new extensions needed for the hospitals that remained, and a slew of former hospital buildings coming onto the market at knock down prices. (p.147) To emphasise her negative points about the medical profession, O’Connor reminds us that the Royal College of Surgeons “Court of Patrons” includes Bernard McNamara of Michael McNamara Builders, auctioneer John Finnegan and also Michael Smurfit. (p.147)
The final chapter of this section of the book, War, examines the nature of the opposition that has emerged to the restructuring of the health service. Given its centralising tendency it is probably no surprise that much of the opposition has been based in localities, particularly in rural areas that were first to feel its affects. There has been local resistance to maternity closures in Monaghan and Dundalk. Over 75,000 people signed a petition in both counties demanding that maternity units be retained. In November 2003, a 25,000 strong demonstration filled the square of the Co. Clare town of Ennis to protest against plans to shut the local hospital’s casualty unit. In September 2006, 10,000 protested in Monaghan at the opening of a new by-pass by the Minister of State. As well as local protests a number of national pressure groups have been formed. These include the National Birth Alliance, which is made up of parents and professionals who oppose the closure of maternity units; and the Health Services Action Group (with which O’Connor is associated) which opposes the centralisation of patient services. (p.163) One opposition tactic has been legal challenges. In 2003, the Monaghan Retention Committee took a legal action on the basis that the health minister had breached the 1970 Health Act. (p.164) Another tactic has been to stand in elections. In Monaghan, independent Paudge Connolly, a former psychiatric nurse, was elected to the Dail in 2002 on a hospital protest vote. (p.165) O’Connor believes that opposition has arisen most strongly in the North East region, Monaghan in particular, as it has been selected to drive the centralisation agenda forward. (p.166)
The final section of Emergency examines the degree to which corporate interests have penetrated the health service. O’Connor places this within the broader neo-liberal framework that has been in place throughout the world over the past twenty-five years. The health sector has not been shielded from this process as market forces have become increasingly dominant. (p175) Ireland plays an important role in the world health market as the biggest net exporter of pharmaceuticals. They account for 44 per cent of Irish exports. Despite this level of production, drugs are more expensive in Ireland than many other European states. Pharmaceutical companies also actively target Ireland as a market. This has involved laying on medical junkets in leading hotels. (p.177) For example, Novartis footed the bill for child psychiatrists to spend two nights in the K Club; Pfizer brought sixty doctors to a rugby match in France. (p.178) Pharmaceutical companies have also targeted patient advocacy groups, with half receiving money or support in kind from the industry. (p.179) One of the key player in this is the European wide “Active Citizens Network”, which is openly dedicated to the privatisation of public services across the EU. Its partners in Ireland have included the Irish Patients Association Ltd, Dublin City University and Age Action Ireland. (p181) Under the guise of a “European Charter of Patients Rights, drugs companies hope to see the introduction of laws that would enshrine entitlements to their products. (p.182)
The Government has also been a major promoter of private for profit health in the past decade. This is taken up by O’Connor in the appropriately titled chapter 13 – Health for Sale. She reveals the serious money that is to be made out of health. For starters, there is the €2 billion spent by the Department on contracting in services. Even the religious orders that control the so-called private not for profit sector are making a killing. In 2003, the Sisters of Charity made a profit of €5.4 million from their three Dublin hospitals. Being a charity there were no tax liabilities. The number of private nursing homes and private for profit hospitals has increased dramatically. This was encouraged by the introduction of tax breaks for companies that built or refurbished public or private hospitals and nursing homes. (p.206) The major push towards privatisation came in July 2005 when the health minister announced a new initiative to provide an extra 1,000 acute hospital beds through the building of private hospitals on public sites. This is the policy of “co-location”. (p.210) While the minister denied it was privatisation, at its core is the transfer of public assets and funds into private hands. Anne Counihan, CEO of the National Development Finance Agency, described co-location as “A very nice little number for the private sector.” (p.212) However, the cost to the public is potentailly astronomical. In 2002, the cost of building a hospital bed directly from public funds was €125,000. Now the minister was quoting €1 million for the same bed – a rise of 900 per cent! (p.214) The claim about freeing up 1000 acute hospital beds was also misleading. Many of these beds are occupied by emergency cases who could not be transferred to private hospitals that lacked the facilities and staff to care for them. (p.216) In terms of cost the policy of co-location is the most expensive, involving the transfer of over €0.5 billion in tax revenues for facilities that would be wholly privately owned. O’Connor describes co-location as a “woodworm that eats away into the nerve centre of the public system, stripping it systematically of its most crucial assets – staff and patients.”(p.218)
In the final section of Emergency Marie O’Connor sets out a number of proposals that could begin to turn around a health system that has “spiralled out of control.”(p239) For her the fundamental problem in the Irish health service is a lack of regulation. She illustrates this by drawing attention to the absurdity of there being no restrictions on human cloning despite Ireland being a Catholic country with a constitution that enshrines a “pro-life” amendment. (p.248) It is this lack of regulation and oversight that has given rise to the many medical scandals in the state, the most notorious one being the scandal of tainted blood when over 1,600 women were contaminated with hepatitis C. (p.243)
O’Connor makes a number of proposals to improve the performance of hospitals. These include: an increase in the number of clinical staff, a major investment in public health system to clear the A&E backlog, the funding of more hospital beds and the employment of more specialist to reduce waiting lists; the extension of GP out of hours cover and end to the outsourcing of hospital catering and cleaning services. (p.244-45) In relation to accountability, she proposes that all hospital’s should be legally required to publish statistics on medical procedures and their outcomes and the introduction of a licensing system backed up by an inspectorate. (p.246) As a means of tackling the staff shortages in hospitals she proposes compulsory public service for all medical graduates trained in the state, and a public only contract for consultants. (p.247) She also proposes the creation of a common waiting list that would see people treated on the basis of need not income. (p.249) O’Connor calls for private non-profit hospitals to be brought under public ownership, and for legislation to block their sale and conversion into for profit entities. (p.255) To restrict corporate influence in the health service she proposes that doctors should be legally barred from investing in for profit hospitals and receiving gifts from companies. (p.256) On top of this, companies would be banned from using health care and educational institutions to promote their products and patients groups would be obliged to disclose their funding. (p.257) In the final chapter, Restoring the Republic, the author makes a call for greater democracy in the health service. This would be achieved by including “genuine” health advocacy and patients groups in the planning process, and giving them greater representation within the authorities that run the health service. The process of centralisation would be reversed by the abolition of the HSE, and the restoration of regional health boards. O’Connor concludes Emergency with a rallying call to readers – “there is still time” she says “time to remind ourselves that we are still a republic, time to say no.” (p.274)
Marie O’Connor, through her writing and activism, is clearly someone who cares about the health of the Irish people and the state of their health services. This comes through clearly in Emergency - a well written, thoroughly researched and passionate exposé of the squalid state our hospitals and the processes that have brought that about. Its publication comes at a most appropriate time as the issues it addresses rise up the political agenda. This makes Emergency a perfect primer for people who want to get active around health issues. However, it does have a number of weaknesses. These arise out of O’Connor’s approach to the subject. She concedes in the introduction that she “writes out of a sense of idealism, a belief in a better world.”(p.x) Her idealism draws on feminism and republicanism, and concepts employed by left libertarian thinkers such as Chomsky and Klein. This enables her to produce a scathing critique of the health service in Ireland, but not to identity why that has come about or how it can be changed. When set beside the preceding chapters that have described in great detail the crisis within our hospitals her proposals to address it appear very weak. They mostly consist of demands for action from a political class who have been complicit in bringing about the crisis in the first place. There is no indication of a political vehicle that could really bring about the changes required. That is not to say that O’Connor proposals are without value. The ones opposing privatisation could be used to as an immediate set of demands to agitate around.
Another problem with O’Connor’s approach is that she tends to see the crisis in the health service as primarily structural. This is why she can make the claim that its problems derive “not from the way it is financed, but from the way in which it has encouraged the growth of medical fiefdoms.”(p.260) She accepts that the health system should be funded through insurance (which is highly regressive) rather than taxation. Although VHI is notionally in public ownership, in practice it behaves like any other private company. Under this type of financing full privatisation is a much simpler step. O’Connor also downplays the broader neo-liberal agenda that has been in place in Ireland for the last twenty-five years. Social Partnership only gets a single mention in the book in relation to the trade union movement dropping its opposition to the outsourcing of public services. (p.223) This would have been a fruitful line to pursue, but O’Connor only brings it up as a means to damn trade unions. A dismissive, if not hostile, attitude towards trade unions runs throughout the book. She lumps professional associations in with the broader union movement, and makes no distinction between trade union leaders and their members.
These weaknesses in Emergency are a result
of its author lacking a class analysis. This limits her ability to
provide an overall critique of the capitalist process and blinds her to
the possibility that the working class is only viable base for an alternative.
What she should be commended for is producing a book that leaves its readers
in no doubt of the depth of the crisis within Irish hospitals. If
it spurs them to think and get active then its impact can only be positive.