The great line in Tennessee Williams’s The Glass Menagerie is the description of the absent father as “a telephone man who fell in love with long distance”. One of Ireland’s biggest problems is that we have a governing culture that is in love with long distance. Its favourite position is at arm’s length from everything that is going on in real time in the real places where citizens interact with the State.
Let me cite two recent examples – one vividly horrific, the other quite dry but in its own way highly eloquent. Between them they help us map the most prominent fissure on the Irish landscape – not the Gap of Dunloe or the Gap of the North, but the gap that yawns between political decision-making and its consequences for ordinary people.
The awful example is the death by neglect of Aoife Johnston, the 16-year-old girl who died from untreated meningitis and sepsis in University Hospital Limerick in December 2022. The report on her death by former chief justice Frank Clarke raised all sorts of questions about the way the hospital operated, with a murky chain of responsibility and failures of basic communication.
We know that six individuals, including the clinical director Prof Brian Lenehan, are facing disciplinary proceedings. The fairness or otherwise of those proceedings will most probably be decided in the courts, to which Prof Lenehan has already appealed.
Chasm between political decision making and its consequences is wider than the Gap of Dunloe
I take no pleasure in saying that Hamas is winning
Government has a windfall of cash but no coherent sense of how to spend it
Sally Rooney gets photographed with an owl, looking unimpressed. I’m asked to ‘look zany’
But Aoife’s death was not caused solely by the actions or inactions of staff at UHL. It was caused by the deliberate and knowing failure by the HSE and the Department of Health to safely integrate accident and emergency services in the midwest. That failure was always going to be lethal.
The midwest had four A&E departments – at St John’s and UHL in Limerick and at Ennis and Nenagh general hospitals. International best practice is to concentrate such dispersed facilities into one centre of excellence and this was recommended by the Howarth report in 2008. UHL was the obvious place to do this.
That report highlighted deep concerns for the safety of patients in the existing, fragmentary configuration of A&E services: “The present system is unsustainable and we strongly recommend the HSE to take prompt action to reduce the current levels of clinical risk and improve patient safety.” This was the overwhelming argument for closing the other A&E departments and folding them all into UHL.
However, because safety was the central concern, the Howarth report stressed that a priority was “maintaining the current service configuration and reducing deficiencies in capacity to meet today’s demands, pending implementation of the new service configuration”. It put in big blue writing the insistence that “the overriding principle is that no acute service will be withdrawn from the current general hospitals until the regional ‘centre of excellence’ is resourced and ready to deliver that service with reference to international quality standards”.
This could not have been clearer. The plan was to enhance the services in Ennis and Nenagh in the short term (to keep patients safe there) and then, when capacity at UHL had been sufficiently expanded, to move them to Limerick.
Instead, the Nenagh and Ennis A&E departments were rapidly run down and then closed in 2009. Patients were funnelled into an already overcrowded UHL, which was not given the promised resources to deal with them. The line from the Department of Health, then overseen by Mary Harney, was that we should be thrilled (as her minister for state Barry Andrews put it in the Dáil) to have “a Minister who is prepared to tackle the vested interests and face down the narrow self-interest that has unfortunately dogged this country’s health policy for too long”.
Objective concerns about safety had become “narrow self-interest”. But Harney, Andrews and the then-government were shielded from the consequences of their decision to disregard the “overriding principle” of the Howarth plan. Forget Kingspan – the greatest manufacturer of insulation in Ireland is the HSE. It creates layers of impenetrable padding between political decision-makers and the consequences of their decisions.
The second example is a recent report commissioned from the OECD by the Minister for Education Norma Foley. Its subject is unglamorous but critically important – the working of the Deis programme that provides additional supports to primary and secondary schools in disadvantaged areas. It touches the lives of 260,000 children.
Great – we need what Foley described as “an independent, expert opinion on the current approach to resourcing schools to support children and young people at risk of educational disadvantage”. Except that this one is invisibly titled Yes, Minister. Its terms of reference are secret – Dr Brian Fleming and Prof Judith Harford of the UCD school of education were (as they wrote in The Irish Times) refused access to them. But essentially, the brief for the OECD experts was to interview officials in Foley’s department and other civil servants. As a group of 30 heads of Deis schools in Dublin noted, the review relied “primarily on self-reporting by the Department of Education who, to no one’s surprise, tell us they are doing a very good job”.
And, farcically, the process was kept, for the most part, well away from children and teachers. The experts visited four Deis schools specially chosen by the department from a total of 1,196 – a sample of 0.3 per cent. Helpfully, there is a schedule of visits in an appendix to the report. Assuming they broke for lunch, it seems to me the experts spent a total of about nine hours actually talking to children and teachers in these schools. This is not their fault – it is what the minister wanted, which is the self-gratification of the love of long distance. No one who made the fatal decisions about the reconfiguration of A&E services in the midwest has to come into contact with conditions on the hospital floor. The lives of kids in disadvantaged schools can be shaped by a largely sealed process that keeps them, as far as possible, out of the closed loop. The shield wall stays up.