Voluntary Organisations and the State

Department of Health, Report of the Independent Review Group established to examine the role of voluntary organisations in publicly funded health and personal social services, Dublin, 2019. (Authors: Catherine Day, chairperson, Jane Grimson and Deirdre Madden).

This report, chaired by the former EU official Catherine Day, is an important document on the future of voluntary organisations in the healthcare system. It was commissioned by the Minister for Health in the aftermath of public controversy in 2017 about the role of the Sisters of Charity in the governance of the proposed new maternity hospital on the St Vincent’s hospital site, and was published in 2019.

Some of the report’s ideas and recommendations have proved controversial. Thus, it received considerable media attention for its comments on the “décor” of faith-based facilities. It should be acknowledged that the report’s recommendation here was expressed in a nuanced way: “voluntary organisations in receipt of state funding should be cognisant of the impact of décor on patients/service users and strive to ensure that their personal preferences in this regard are met to the greatest extent possible” (Recommendation 7.2).

Nevertheless, this recommendation seems reductive. One might question whether, for example, a crucifix recalling the death of Christ for humanity, and reflecting the founding inspiration of a hospital, can be equated with the design features or “décor” of such a hospital.

One might also question the report’s approach to the interaction between the State and faith-based bodies. The report declines to recommend – as many in Government appear to believe – that faith-based voluntary bodies in receipt of public funding should simply be compelled to provide services contrary to their ethos. However, the reasons it gives for this approach are pragmatic rather than rooted in the rights of voluntary bodies to follow their fundamental ethical principles.

The report argues instead that such efforts at compulsion could lead to considerable disruption in a context where the faith-based component of the health sector remains substantial and thus suggests other ways in which the State could ensure “access to lawful services by all its citizens” (Par. 2.1).

These reservations aside, this is a significant report that shows a welcome respect for the historical and contemporary contribution of voluntary organisations in Irish healthcare.

It draws attention to the “debt of gratitude” that the country owes to voluntary organisations in healthcare, praises them for their innovation, flexibility, independence and strong commitment to delivery of health and social care and highlights the requirement for such bodies to collaborate in an accountable way with the State. It points out that the faith-based element of the voluntary sector, while declining, remains substantial.

Its many important recommendations cover areas such as protection for State investment in capital assets, multi-annual budgets, the public recognition of voluntary bodies through a charter and the establishment of a Forum to facilitate State/voluntary dialogue. The report also acknowledges tensions in the HSE/voluntary relationship and calls for a new relationship based on trust, partnership and mutual recognition of need. It also includes valuable information on trends in other countries, even if its comparison with England is somewhat questionable, given that the voluntary sector has had, for many decades, a much stronger role in Ireland than in England.

Advocates of the subsidiarity principle – a key principle of Catholic social thought – argue that, before devising ambitious plans for health or other services, policy-makers ought to start by looking at the services that are already there, at what has been developed by civil society, and then build on that rather than try to establish new systems entirely from scratch.

In many respects, this report could be seen as adopting an approach that is in harmony with such thinking. Thus, it examined the voluntary organisations that exist at the moment in Ireland, consulted in detail with them and highlighted their “added value”, provided valuable information on their ownership and governance arrangements, and offered various ideas for integrating their work and that of the State.

This approach is somewhat at odds with that of the current all-party plan for the health services, Sláintecare, which was published in 2017. Sláintecare provided a very thorough reflection on the Irish healthcare system and sought to respond effectively to major problems and inequalities in that system. It developed an ambitious plan based broadly on socialist principles but expressed unease that much of the Irish public health service was in “private ownership” and had a somewhat dismissive attitude to publicly funded voluntary bodies. Thus, while it did recognise the important advocacy role of many charities, it also called for a detailed plan to provide for the divestment” of Section 38 and 39 healthcare voluntary bodies “over a reasonable period” (Section 3.8).

Some other statutory publications have suffered from a similar lack of due regard for the contribution of voluntary organisations. Such bodies were not included, for example, in the list of key healthcare stakeholders set out some years ago in the strategy document, Future Health.

While the State has a critical role in healthcare, the Day report may represent a welcome turning away from excessively State-oriented perspectives. It will be of interest to those with a specialist interest in health policy but could be read with profit by any interested citizen and its data on the current ownership and governance arrangements of voluntary bodies are of particular value. It is accessible on the publications section of the Department of Health website, at health.gov.ie.