Remove the element of accountability, and the bureaucracy always wins. And when unaccountable bureaucracy wins, citizens lose, writes Fergus Finlay

When the director- general of the HSE is called before the Public Accounts committee, again and again, to clarify what he told the committee the last time, you know there’s a serious problem.

Several times now, Tony O’Brien has been accused of misleading the committee and the public, of withholding information he should have released, and of trying to prevent the truth from coming out. The RTÉ This Week programme, and especially Daniel McConnell in this newspaper, have been repeatedly frustrated in trying to get to the question of accountability in the story behind the case of Grace.

Simple questions, asked a number of times, get increasingly complicated answers. Who made the decisions that condemned Grace to a period of abuse and neglect? Who ignored the mounting evidence that ensured other young people were removed from an abusive setting, but left Grace there? Are those people still working in the public service? Has any action been taken against them? Why were damning reports not published for years?

The more the answers emerge — or rather, the more the answers are forced out of what appears to be a highly reluctant director-general — the more it appears that the HSE is interested only in covering up what really happened. On the surface, the director-general of the HSE appears to be unwilling to say, at any point, that he will act decisively to ensure full accountability.

One of the results of this seeming reluctance is that there is now a Commission of Inquiry into the entire case. For the first time that I can remember, one of the terms of reference of the commission obliges them to enquire into whether or not there was a cover-up within the HSE. It’s very specific: “Establish the facts relating to whether there was any deliberate suppression or attempted suppression of information during the period 1996 to 2016 … in relation to Grace’s case, including, but not limited to, an alleged danger of deliberate destruction of files or alleged threats by the HSE to the funding of the agency whose staff made protected disclosures.”

As I said, I don’t ever remember a Commission of Inquiry being specifically tasked with establishing whether or not a cover-up was deliberately attempted. To be sure, previous commissions — notably the Inquiry into abuse within the Dublin diocese — found many instances of cover-up as it went about its work. But finding a cover-up wasn’t part of its original terms of reference.

I think if I was the head of the HSE, faced with terms of reference like this, I’d be deeply troubled. And I’d be determined to ensure that no such allegation was capable of being substantiated on my watch. But instead, the complicated answers to simple questions, often couched in legalese, simply bolster the ongoing impression.

What’s the truth of all this? I don’t know Tony O’Brien — I’ve never had a face-to-face conversation with him. But everyone I know who knows him respects him, and regards him as someone who is tough on one hand and transparently honest on the other. And my own judgement of his actions over the years, for what it’s worth, suggest a man who is determined to build a health service that is both responsive and compassionate. A while ago, (I think in the wake of the Áras Attracta scandal) he wrote a passionate letter to every employee of the HSE, almost imploring them to respond to every individual in their care as if he or she was a member of their family.

That’s not the way Grace was treated, and it’s not the way the HSE has responded to the treatment of Grace. Do you know what I think that tells us?

I think it tells us that bureaucracies are impervious to passion — or any other human emotion, for that matter. Tony O’Brien is the boss of the biggest bureaucracy we have ever built in Ireland. It’s that fact, more than any other, that has frustrated us — and, I suspect, him — from getting to the truth.

We haven’t just built a huge, impenetrable, bureaucracy, we’ve even passed laws to ensure it cannot really be accountable. Back in 2012, the then health minister, James Reilly, had the bright idea that he was going to abolish the HSE and replace it with something more manageable. But he told the Seanad and the Dáil that, as part of the process, the first thing to do was to abolish the board of the HSE, and replace it with a directorate. The head of the directorate was to be the director-general, and nobody could be appointed to the directorate unless they were also a senior employee of the HSE.

I don’t know how anyone thought this was a good idea, because it is absolutely nutty to set up a massive bureaucracy and then legislate to make it account, on a daily basis, to itself. Perhaps it could have been justified as some kind of transitional arrangement but, four or five years later, that’s how the HSE operates. Tony O’Brien and his senior team, for all practical operational purposes, report to Tony O’Brien and his team.

There has been a huge emphasis on good governance in recent years — some of it driven by a desire for better practice, but much of it driven by scandal. The rules that apply to semi-state bodies all over the place are designed, in principle at least, to ensure accountability. For example, there are 20-odd pages of semi-state bodies in the Institute of Public Administration (IPA) yearbook, dozens more public bodies in the education sector, and hundreds of non-governmental organisations.

You can go through them all, and, with a tiny number of exceptions, the thing they all have in common is that the chief executive reports to a board. If those boards aren’t independent, that has been clearly seen and described, by bodies such as the IPA, as a breach of good governance.

But for some mad reason that doesn’t apply to the daddy of them all, the HSE. It was set up in the first place so that politicians could make themselves less accountable for the health service, and is has become less and less accountable over time — facilitated by crazy legal changes that make it effectively only accountable to itself.

Now, this directorate, to whom the directors report, keeps itself very busy. It seems, to judge by the HSE website, to meet once a fortnight or so, always with a packed agenda. It publishes highly stylised minutes of its meetings, eventually. I’ve been poring through those minutes (admittedly, I haven’t had the strength to read them all), looking for words such as scandal, Grace, accountability. I haven’t found them, and I’m pretty sure I never will.

I’ve argued for years that the HSE should be abolished, and that we need to start again to build an accountable and responsive — and value for money — health system from scratch. In the end, it doesn’t matter how well-intentioned, or honourable, or decent the chief executive or his team is. Remove the element of accountability, and the bureaucracy always wins.

And when unaccountable bureaucracy wins, citizens lose. Especially the citizen without power and without a voice.


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