SECOND OPINION:System-wide failings went on for four decades, writes DESMOND O'NEILL
IT IS SAD THAT the memory of Lord Denning, the eminent jurist, will always be associated with the unhappy phrase “appalling vista”, pronounced during the appeal hearing of the Birmingham Six. By this he meant that prolonged, pervasive and systematic wrongdoing by agencies of the state was inconceivable: subsequent scrutiny was to prove him misguided.
Such system-wide failings are not a monopoly of any one nation, and the Irish Ombudsman presented an equally appalling vista to the Irish people and Government recently. Concerned about persistent complaints over 25 years by older people and their relatives over failure to inform them of their rights to publicly funded nursing home care, she launched an extensive investigation.
Her findings were quite categorical in confirming what many clinicians already suspected: for almost 40 years the State failed to clarify eligibility under an 1970 Act of Parliament which established a right to publicly funded long-term care to those who needed it.
This left a vacuum whereby the vulnerable, disempowered and voiceless – knowing little better – opted for either a lesser subvention (a fraction of the cost) or paid the full cost. Those in the know, and those with feisty advocates, could avail of this eligibility as either a publicly funded place in a private nursing home, or in a public or voluntary nursing home. Nearly the only way to be in a position to do this was from a hospital bed, but those who did so were often vilified as “bed-blockers” or seen as unreasonable.
Some of the most heart-breaking scenes in my clinic over 20 years were from families who were cracking under the financial pressure, yet felt unable to use the only routes to a publicly funded bed. These were either to sue the health services – a risky and potentially costly process – or to engineer a return to the emergency room and hospital.
Our unit and hospital came under frequent pressure not to clarify the eligibility: our rejoinder that we would comply with instructions to that effect in writing never prompted a written reply.
Indeed, at one meeting of very senior health service executives, the conversation took a pointed turn to criticising geriatricians who clarified this eligibility. I tried to short-circuit this by again asking for written direction, and was told that “geriatricians should know the score”.
This typified the depth and breadth of complicity/collusion with a deliberate ambivalence that effectively concealed an important entitlement from many vulnerable people.
It is, therefore, not surprising that the Ombudsman expressed concern about the failure of the Department of Health and health service to provide information which she required.
A further unfortunate consequence of the lack of clarity over eligibility was the build-up of a large constituency of the aggrieved, who were paying the full or partial cost of nursing home care. These then welcomed a scheme called the “Fair Deal” set up in 2009: older people pay 80 per cent of their income and, after death, 5 per cent per annum of the value of their house (for up to three years), and 5 per cent of their assets, the most dramatic loss of an eligibility in the history of Irish healthcare. Ironically, this was promoted on the supposed inequity of some getting publicly funded care, rather than the real inequity of the failure to inform, and support access to, publicly funded care.
While compensation for those affected between 1970 and 2009 is likely to follow its own logic, a deeper malaise to be resolved is how to ensure a space for virtuous thought and action in health services.
It is a measure of the man that Lord Denning could admit 11 years later that he had been wrong about the appalling vista: as physicians we should take note and aim to create a healthcare system that allows us to make space for recognising where we have erred, make amends, and do better next time, particularly for a vulnerable group which many of us will join in time.
Desmond O’Neill is a consultant in geriatric and stroke medicine in Dublin