`The use of history is to give value to the present hour.' This quotation from Ralph Waldo Emerson is particularly apt in seeking solutions to the current crisis in the Irish health system. We must examine how the health services developed in recent decades to the point where they are now characterised by continuing exposures of appalling failures to provide appropriate care:

the elderly, as evidenced by the Ombudsman's indictment of the behaviour of the State in relation to citizens in nursing homes;

the young, as evidenced by the Report of the Irish Social Services Inspectorate on Newtown House;

those in need of emergency care, as evidenced by the resignation of Accident and Emergency consultant Mr Patrick Plunkett from the board of St James's Hospital because he was "unable to stand over the mess that presents itself to me on a daily basis";

patients awaiting serious operations, as evidenced by long waiting lists for acute public hospital operations;

patients who were fatally infected by blood products by the health system as evidenced in the Lindsay tribunal of inquiry.

This litany of the failures of the health system might be extended ad nauseum.

All of these gross failures share a common root in the values which have shaped our healthcare system since the 1980s. The operative ideology in the State's institutions is based on the beliefs that health and social services are a commodity that is provided to "customers" and that the State's financing of these services should be financed by the application of "market type" measures (more output for less financial input). If you cannot pay for services then you suffer more or you die sooner than those with the financial means to buy healthcare.

This "managerial" ideology took hold of the Irish health services in the Thatcherite/Reaganite 1980s when Ireland had a public expenditure crisis. It became dominant in the 1990s and has remained so despite the transformation of the economy and the scope for public expenditure. The result has been the erosion of the trust citizens ought to be able to place in their health services and the demoralisation of those professions which wish to provide a high quality of care.

In order to bring forward a new national health strategy we will have to replace this failed ideology with new principles and values. The aspiration of a new health strategy should be a citizencentred comprehensive health service providing equality of treatment for all.

Patients are first and foremost citizens. One of the fundamental rights of all citizens is the right to accessible, responsive and quality healthcare - to be provided, when required, to everybody, regardless of income or social status. The "managerial" ideology has displaced citizens from a central participative role in shaping healthcare and from taking responsibility for community health services. It has created a very large number of "managers" and "managerial" structures which have manifestly failed our people.

In reaction to the impoverished language of the market which describes people as "customers" (which has become common in the managerialist Irish public service under the aptly-entitled "Strategic Management Initiative") there has been a welcome return to the richer language of citizenship in public debate.

In public policy discourse (most notably that of Robert D. Putnam's Bowling Alone: The Collapse and Revival of American Community, New York, 2000) it is now becoming understood that a more developed philosophy of citizenship is essential to ensure the social solidarity so essential in public services such as health: a shift is required from a society of unequal customers to a society of equal citizens. This will require that the public administration of our Irish health services in the future must be governed by citizens rather than ruled by "managers".

The story of the evolution of the new public voluntary hospital at Tallaght is an instructive case history of "managerialism" in action. It begins in the 1980s as health service "managers" close a range of famous voluntary hospitals such as Sir Patrick Dun's, Dr Steevens's, Mercers', Baggot Street and Barrington's Hospital in Limerick. This sparked a 10year controversy on the future of the Adelaide Hospital - the last voluntary hospital under Protestant auspices in the State.

During the controversy a number of general principles were enunciated and eventually enshrined in the new Adelaide & Meath Hospitals' charter, approved by the Oireachtas in 1996:

that voluntary organisations should be partners with the State in the provision of public services;

that the role of minorities should be recognised and fostered in the provision of public services;

that the patient's right to confidential medical treatment should be explicitly recognised to facilitate citizen choice in healthcare;

that health services should be developed in the interests of patients and should be based on inclusive values, such as respect for and care of the whole person and equality of treatment for all.

These four general principles may now be seen as keys to the reform of our health services in the interests of citizens and their healthcare.

Voluntary Governance of Public Services policy in support of citizen-based voluntary agencies providing public services has developed greatly since the Adelaide Hospital raised this general principle in respect of hospital services in the 1980s. In September 2000 the Government published a landmark "White Paper Supporting Voluntary Activity" committing the Government to support voluntary organisations as partners in the provision of services within an enabling State.

The new voluntary hospital at Tallaght may be seen in the light of this public policy as a prototype for the provision of Irish hospital services in the 21st century.

The recent major policy on the reform of Irish health services, issued in November 2000 by Fine Gael, "Restoring Trust: A Health Plan For the Nation", proposes citizen involvement in healthcare through voluntary organisations and citizen-based boards of governance for all healthcare providers.

"Fine Gael will ensure that all public voluntary hospitals are governed by independent voluntary citizen-based boards, reversing the practice of using the Health (Corporate Bodies) Act 1961 to appoint their boards by ministerial appointment."

The purpose of this is to ensure there is a "voice" for patients at the board table and that independence and fairness are characteristic of such boards. This year is the UN Year of the Volunteer and it is national policy to promote volunteering by active citizens in the interests of the welfare of others. The new hospital at Tallaght, indeed, has pioneered hospital volunteer services to assist hospital staff in providing a higher quality of care for patients and families.

Pluralism in Healthcare

Irish Society in 2001 is more diverse and contains many more minorities than even a decade ago when the Adelaide contended for a positive role for minorities, such as the Protestant community, in the provision of services to others. It is worth recollecting that the Adelaide Hospital (alone of all hospitals) in 1994 made a submission to the Forum for Peace and Reconciliation entitled "The Adelaide Hospital: Symbol of Expression of a Plural Society", which stated:

"Different traditions in a pluralist society can only make their full contribution through voluntary organisations and initiative. The State, if it wishes to foster pluralism, must support such voluntary effort as a matter of priority and in a positive way as against a creeping, centralising, homogenising form of government.

"It will be through such voluntary effort that diverse traditions will be able to make their special and distinctive contribution to the whole of society."

It is sad to observe the continuing difficulties many institutions and people have in the Republic welcoming refugees and embracing difference as represented by minorities of many kinds. The recent report, "Peace Building in the Republic of Ireland", published in December 2000 by the Irish Peace and Reconciliation Platform, makes sobering reading in this regard.

Honesty compels those who experienced the rocky development of the new Adelaide as a focus for Protestant participation in our hospital services in a multi-denominational and pluralist setting to state that exclusive mindsets remain seriously opposed to an inclusive society in the Republic

The charter of the hospital in many ways parallels the Good Friday agreement in respect of the need to fully embrace commitments made. Why, for example, is the new hospital the only university teaching hospital in Dublin which is not represented on the new Comhairle na nOspideal, appointed recently?

Despite reluctant support of many from whom more could have been expected the new hospital has demonstrated a positive capacity to embrace minorities of all kinds as patients, as staff and as different communities. It would be refreshing if it did not have to operate so constantly as an exception rather than as the norm for Irish society in the new century. The legislative framework represented by the Equality Act and the Equal Status Act should surely mean that we have finally become a republic that wishes to cherish all equally.

Ethics and the future of Healthcare

Healthcare is fundamentally an ethical pursuit. Throughout the 1990s the supporters of the Adelaide contended that patients had a right to a confidential relationship with their doctors without being second-guessed by an ethics committee in relation to their medical treatment. In other words, citizens have a right to full information about their health and to decide, upon the advice of their freely chosen doctor, on their treatment as medically indicated.

The new Adelaide and Meath Hospital is the only hospital in the Republic in which these patient rights are enshrined in the governing charter of the hospital and which has the backing of law.

As we continue to face great ethical issues as medical science develops, those rights are even more important for the future than in the past 2. At the heart of public concern about Irish healthcare is lack of trust among citizens that they will be accorded full respect as citizens and given appropriate medical treatment in accordance with their own personal beliefs and values. Reform of Irish healthcare in the wake of the sad failures so frequently documented must surely embrace the ethical stance pioneered by the Adelaide and Meath Hospital as the only appropriate stance for citizens in a republic.

Health Services in the interests of Patients

A key object of the Adelaide and Meath Hospital according to the charter is to manage and provide services "in the interests of patients". It is curious how many of our institutions are now effectively managed in the interests of other groups besides those served by them - schools for teachers instead of students, prisons for prison staff instead of prisoners and healthcare for "political" purposes. There is much rhetoric about "patient focused care" which obscures the reality of services being organised to meet the needs of others besides patients.

A critical element of any new healthcare strategy will be to reform services genuinely around those who use the services. The proposal to give citizens a more powerful "voice" at board level of all healthcare agencies, if carried through, would be a major step forward for patients.

The general principles identified in the 1990s as the basis for the most modern university teaching hospital in the Republic are crucial to healthcare reform. In particular, the concept of equality of the treatment for all patients is shamefully ignored in our "two tier" health system where financial means so often determines access to care. As citizens we must continue to identify and challenge the values that actually operate in healthcare and to promote reform of Irish health on principles and values that will offer the highest quality of care for all.

1. A detailed analysis of the experiences of the first board of the new hospital is provided in Fergus O'Ferrall's Citizenship and Public Service Voluntary and Statutory Relationships in Irish Healthcare (Adelaide Hospital Society in association with Dundealgan Press, Dundalk, 2000) pp161-224.

2. See Medical Ethics and the Future of Healthcare eds. K Kearon and F O'Ferrall (Columba Press, 2000)

Dr Fergus O'Ferrall is director of the Adelaide Hospital Society and author of Citizenship and Public Service Voluntary and Statutory Relationships in Irish Healthcare, published in 2000.