A culture of confrontation has blighted the State's interaction with the health professions, writes Ray Kinsella.
The root cause of the nurses' dispute is not militancy. It is the culture of adversarialism and confrontation that is increasingly evident in the manner in which the State has chosen to interact with the health system over a number of years.
This negative, demoralising and ultimately counter-productive approach is not alone evident in the manner and tone in which the nurses' dispute is being managed; it has been a feature of ongoing relations with hospital consultants in which discussions over pay and hours worked are really a proxy for control.
On two occasions in recent years the State has unilaterally imposed conditions on hospital consultants. There is now a threat to do so again in relation to the condition attaching to desperately needed additional consultant posts. So, while the immediate occasion of the nurses' dispute may relate to the length of their working week, pay levels and relativities, there is a deeper cause for concern. When the dispute is resolved, and it will be, these wider issues will remain.
What has, until now, been perceived by the public as a set of unrelated issues - the nurses' dispute, the governance of the medical council, contractual arrangements and the leadership role of consultants in what is ostensibly to be a consultant-provided medical service, are now coalescing together in the public perception.
There is something wrong when a culture of adversarialism encompasses an entire profession.
The centralisation of power, which runs contrary to the philosophy underlying the Health Act 2004, should carry a health warning. It threatens to erode the practitioner and patient relationship. It is transferring power and responsibility away from the waiting room, the ward, the theatre and the research laboratory to the State. The attempted capture by the State of medical regulation and governance and, by extension, ethics, seems increasingly clear.
It is a demonstrably misconceived approach, in a highly expert and vocationally driven set of professions. Unless reversed, it will cast a very long shadow over the future of Irish healthcare. In terms of the general election, it is the single most important issue, since it shapes all other issues in relation to healthcare.
In a celebrated study in the Harvard Business Review some years ago, humility emerged as the defining characteristic of leadership. There is a conspicuous need for humility, both in resolving the nurses' dispute and reversing this culture of adversarialism.
The professional medical bodies need to look carefully at their governance and regulation to ensure it is grounded in the kind of responsibilities that are an integral part of the profession, as well as in ensuring that structures are responsive to changing public expectations.
They need to be seen to be passionate advocates of the interests of patients, and not only because the care of the patient is ultimately, quite literally, in their hands.
The State needs to acknowledge that professionals on whose skills and commitment they routinely depend upon in their own lives, can be trusted to manage their own affairs and look out for the interests of patients. It is, after all, what brought them into the profession in the first place.
Regarding the present dispute, the denial, over an extended period of time, of a working week that is equivalent to that of other professionals and of management, is simply wrong.
At best, it indicates a lack of strategic planning - at worst a lack of interest and a presumption on the goodwill of professionals working in an emotional, physical and at times anti-social environment.
In the ritualistic exchanges that prevent us moving swiftly to a resolution much is being made of the financial costs and the number of equivalent posts involved in a transition to a 35-hour week. Just as in the case of the European directive, the State has had long enough to do its sums.
What's done is done, however, and it may take some time to work out the logistics. But the policy failures in relation to the supply of posts and the failure to retain nurses - and the concomitant, wholly immoral dependence on nurses from overseas - will become all too apparent. However, an unequivocal commitment, time-lined and independently verified by, for example, the National Implantation Body, should be made now. This could take one of the major issues off the table.
The issue of pay negotiations is more problematic. In the welter of claim and counter-claim, one point is clear, nurses are not well paid. Both the starting salaries and the bands do not reflect either the length of time involved in training or the responsibilities entailed in delivering care in a highly-demanding environment.
There are well-documented and glaringly obvious anomalies. Productivity gains are usually a part of a resolution of the pay element of any dispute. A mandatory reduction in the number of meetings that contribute little to effective management and nothing whatever to direct patient care would resolve the productivity issue. A comparison with world class organisations bears out this point and the nursing profession and their colleagues know this better than anyone.
The infrastructure of industrial relations is important as an element in the State's strategy of centralised benchmarking. There is a view that the nursing profession has not been well served by benchmarking. At the same time, the State is worried that if the pay element of this dispute was to be dealt with outside of the established infrastructure, then the floodgates would be opened. Instruments such as benchmarking are there to serve a purpose. They are not there as totem poles behind which to take refuge from the most basic need in this whole dispute, that is for the State to engage in dialogue on what is a demonstrable and long-standing failure of policy in this area. And it is the State that has to take responsibility. The HSE has inherited, not caused , this problem.
If social partnership means anything, then dialogue between the State and a profession that is central to the functioning of a civilised country is imperative.
The National Implementation Body has taken a commendable initiative in this regard and, with goodwill on both sides, could provide a framework within which to resolve the dispute.
The dispute is, however, causing increasing difficulties for senior management, nursing and medical staff. It is causing hurt, frustration and a further lowering of morale.
It is diverting attention away from the frequently invisible, but enormously innovative, work going on within parts of the HSE.
Most important of all, unless resolved quickly, the escalation of this dispute will leave a legacy of division. It is simplistic in the extreme to imagine a simple return the status quo - life is not like that. It will further shift nursing, and also medical practice in general - which is still a largely vocationally driven profession - in the direction of a utilitarian, process-driven, metric-obsessed job. One that is far removed from the service ethos bequeathed to the Irish health sector by the religious nursing orders as well as their professional predecessors.
When the nurses' dispute is resolved, the most urgent priority for the next administration, whichever it may be, is not more institutional change or more legislation or more regulation. It is the simple, powerful imperative of building trust between the State and the health professions. In the light of our history, it will take truly exemplary leadership to understand that those to whom we commit our healthcare needs are worthy of that trust.
There have been and are, deficiencies in governance within both the healthcare professions and, even more notably, within the State.
There is a place for humility. There is a need for organisational learning. The proper custodians of governance and regulation in the health service are those who have the ultimate responsibility for delivering such care.
Ray Kinsella is a professor at the Smurfit Graduate School and the author ofAcute Healthcare in Ireland . (Oakley Press)