What on earth does the Department of Health actually do?

With public services in the spotlight, in particular the health services, the silent machine of the Department of Health (DoH) manages to dodge most attention. So what does the Department of Health actually do? How many people work there and what is its budget? How as it changed since the establishment of the HSE in 2005? Is it providing good value for money? The mission of the DoH is to improve the health and wellbeing of the Irish people and oversee health and social service provision (“fair access, responsive and appropriate care delivery, and high performance”). Like all government departments, they are responsible for formulating policy, drafting legislation, and participation in the democratic process such as answering Parliamentary Questions (PQs) and serving their Ministers. These processes take up a lot of time.

As well as Mary Harney (in post for 5 years) there are 3 ministers of State, Andrews (children), Maloney (mental health and disability), Aine Brady (older people and health promotion). Much time is spent servicing the ministers.

I worked in the Department of Health between 1997 and 1999 – a long time ago – but many of the day to day realities remain the same. I found

• A lot of time was spent doing that bread and butter work, policy, drafting legislation & redrafting, getting it through the Oireachtas.
• It was, and I suspect still is, a very hierarchical institution.
• Grades and status matter – where your office is depends on your status.
• It is very male dominated.
• A lot of time and energy goes into servicing ministers and the political process – responding to PQs, 2008 – 6,139 PQs last year of which half were referred to the HSE -  20% of all PQ’s put down by members of Dáil are health related.
• The Department is responsible for international work, EU directives, WHO, North-South work.
• There are some really good, intelligent, hard working people.
• And there is a significant amount of dead wood and one of the problems in the public service is you can’t get rid of people unless they are really awful.
• When I was there the DoH was also directly responsible for the health budget and management of health and social services, so that is very different now.

Since the establishment of the HSE in 2005, the role of the Department has changed. On 1 January 2005, the Health Service Executive came into existence – this amalgamated all health and social services, hospitals, community care areas, it dismantled the old health boards and put everything under control of HSE. Up to then, all those agencies reported directly to the Department of Health and also got their money from the DoH.

And it is the funding that is the crucial matter, because the vast majority of the €16 billion health budget now goes directly to the HSE NOT the DoH. The Department’s own budget is approx half a billion euro (€498 million in 2008) but most of this goes to directly fund agencies which are not part of the HSE e.g. NTPF, Ombudsman for Children, Mental Health Commission, HIQA, Health Research Board.

The Department’s own budget is €45 million. The Office for Minister of Children has its own budget of €693 million, this included now abolished early childcare payment. The Department now has 475 staff. In 2004, there were 650 staff so it has decreased in size as well as changing its role – over a 25 per cent cull in staff. Also it has just lost 28 staff in early retirement schemes and a particular problem for them right now is that eight of these were at Principal Officer level – nearly one quarter  of all POs. This is a huge loss in organisational knowledge.

The department is structured with a Secretary General – Michael Scanlon (who gets paid €220 k), 6 assistant secretaries (€130k+), who are the Management Team, there are also three directors in three ministers of states offices and recently the CMO joined (who are on similar €130+ salary scales).

The relationship between the Department of Health and the HSE has changed significantly since 2005. No one in the department ever believed the Minister would give away the budget to the HSE. As one civil servant who worked there at the time told me – “the department was emasculated when the budget was handed over to the HSE – because whoever holds the purse strings holds the power.”

It is meant to be that the department develops policies and the HSE that executes them. However there is still a lot of confusion about who does what, so this does not happen in reality. There is a lot of mirroring of roles, the Department overseeing what the HSE does. Also, in the consultants contract negotiations  and in the current social partnership talks about knocking €1.3 billion off the public pay bill, both the DoH and HSE are at the table. There is definitely duplication of roles & there is also power mongering & rivalry.

For example, once a confidential/internal report is sent from the HSE to the DoH for information or response, the HSE are guaranteed a press query on it within the hour from a major national news group. Clearly they are not working together – this is undermining and hardly the best use of our public servants time.

Speaking at an Oireachtas Committee recently Michael Scanlon said “we work together on a daily basis to try to ensure that the best possible services are provided to the people of Ireland”. This may be the rhetoric but it is not the reality. Is it unreasonable to expect all public servants working in the health area to work together to spend the €16 billion health budget effectively rather than undermine each other?

This confusion between the HSE and the DoH has its origins in the 2004 Health Act which established the HSE but spectacularly failed to clarify the role of the Department.

• The role of the department was not mentioned in the Health Act.
• Post- 2005 the DoH was meant to be restructured – this has not happened.
• The 1989 Commission on Health funding which said who is in charge of what in the health service is not clear.
• OECD report on public services also made this point.

Despite Mary Harney’s zeal for reform she has spectacularly failed to reform her own house.

There any however some examples of where it does work well, of good practice by our civil servants in health. We are actually quite good at developing policy, just bad at making it happen. However, two areas where we have been successful in health policy development and implementation even international are:

• The smoking ban
• The Office of the Minister for Children

The crucial ingredients in this are a really driven civil servant, someone with a vision and the brains but also the political nous to bring about change and persuade the minister that it is their idea.

But in most instances change is very slow and incremental.

Change takes time but to change an organisation like the Department of health you really need vision and leadership… there has been a distinct lack of that – if we had that leadership and vision – we might not have the system we have today – we might have a universal system based on need, not ability to pay.