Many of those who know most about the health service fear to speak. It is ironic that as our anxiety about the health service mounts, and as the Cabinet goes into high-profile conclave on the issue, the people who know what is happening in our hospitals are afraid to share their insights.

Two weeks ago, I facilitated a workshop at the Irish Nurses Organisation conference in Killarney. In a hot upstairs room on a blazing day, nurses grappled for two hours with how to use their insights to effect reform in the health service.

Having been invited to make some introductory remarks, I had suggested that nurses could add greatly to the reality of the health debate if they followed the example of the Society of St Vincent de Paul, which had provided illuminating illustrations of the operation of the two-tier system from the experience of its members.

"If we exposed what we know, we would have the life of a dog. Do you not agree?" one nurse asked her colleagues.

"We are the patients' advocates and shouldn't be afraid of other health professionals in speaking out," another urged. "But we are," the room responded. "As nurses, we are undervalued for what we do in Ireland. Until we find our voices, we won't be heard," encouraged one speaker.

"We have no voice at all," concluded an older woman.

At the workshop, which was open to the reporting media, nurses gave a taste of what we might hear if they truly found their voice. They speak best for themselves.

On the two-tier system: "I feel guilty that I haven't spoken out. Our hospital is in crisis. We are constantly cancelling our day services. It is the public patients who are cancelled, not the private patients. The consultants take the decision, on medical grounds they say. But we see the notes; we can't see any difference." "I monitored the attendance and quality of our outpatient services and challenged the inequity. I was accused of being opposed to private practice."

"A young man in about 30. I saw the name of who was on call. I thought: he's dead, anyway, before he starts. Then I saw he was in the VHI. Thank God, I thought. So I said to the patient: 'You are requesting the cardiologist on call, aren't you? Mind you, I am not saying this, but you are requesting the cardiologist, because it's the diabetes doctor who is on call.' If that had been a public patient, I could have done nothing for him."

"I see public patients ringing everyone they can think of to try to get to speak to a consultant. I see the consultant saying to the private patient in the bed: 'give me your husband's mobile-phone number and I'll call him about your progress.'"

"The two-tier system exists in all hospitals. The private sector is a business. In the Blackrock Clinic and the Mater, tests using expensive instrumentation go on the patient's bill. In the public sector, the taxpayer pays for it."

"I worked in Denmark. It was a fantastic system, the respect nurses had there. Nurses knew their rights and they knew the rights of the patient. If a private patient came in, they said: 'you will have to find a private nurse.'"

On junior doctors and the absence of supervision: "You know when the SHO [senior house officer] hasn't a clue. A patient was in cardiac arrest and the doctor hadn't a notion what was going on. At one stage I gave the drugs because she hadn't a clue. No one is supervising them. No one is training them."

On who runs the health service: "Who controls access to the hospitals? The medical profession. The politicians won't take them on, although they know what's going on. It is a conspiracy against the patient to keep power vested in the medical profession."

"Consultants treat managers with utmost disdain. We have had four hospital managers in the last few years, none with experience of the acute setting. They do not have the qualifications to do their jobs. They receive no support from the consultants, who won't go to management meetings."

"We need to put some control back into the health system. Managers can't control consultants because they say that is questioning their clinical abilities." "The consultants treat managers with utter contempt. Our management are not educationally equipped to cope with consultants and control them."

"We are living with the legacy of the health cuts, with a shortage of beds for acute patients. We have excellent consultants. I feel their hands are tied when it comes to the health boards. Too many people are making decisions or not making decisions."

Not everyone agreed that nurses should take it upon themselves to share these perspectives.

"We should not do Michael Kelly's work for him," one speaker said about the secretary general of the Department of Health and Children.

"We say what is needed again and again, but they never, ever listen. We need more geriatricians, more nursing input, more acute medical and surgical assessment units. This is what we should demand, and not have individual people spying on individual colleagues."

Following last week's Cabinet meeting in Ballymascanlon, Co Louth, debate mounted about whether the health services need spending or reform. The view from Killarney was clear: both.

mawren@irish-times.ie