GERARD HOWLIN: Playing blind man’s buff with the country’s most complex organisation

It is three weeks today since the judgment in the Vicky Phelan case sparked off the CervicalCheck scandal. Sadly, because of the seriousness of the issues, there is scaremongering about the safety of the cervical screening programme.

What is known is that essential, important information about misdiagnosis in a screening programme, which was never going to deliver fully accurate results, was not conveyed to patients when subsequent diagnostic tests showed them to have cancer.

Tragically, some of those cases are at an advanced stage. Eighteen women affected have since died.

What is not clear, and should not be assumed, is whether the quality of our Irish screening programme is substandard compared to best practice elsewhere. Thus far, this is about information and power. If there is more, it remains to be seen.

Context is essential — not just to separate what is fact from what now must be thoroughly examined to be sure.

It is even more essential if what has gone wrong is to be forensically focused on. The word “hysteria” has been used. One comment I saw fairly pointed out that it is gender-loaded.

Much of what I have heard has been masculine “exaggerated or uncontrollable emotion or excitement”, to use a formal definition of the term.

The problem is, that unfocused anger suits the system that is responsible for the specific issue and the culture of power, entitlement and obduracy that begat it.

One head has already rolled — that of Tony O’Brien. Others will too. However, significant that may be for individuals, it is almost irrelevant to the structures, accountability and culture of the systems involved which remain essentially undisturbed.

There may, however, be one noticeable difference afterwards. In organisations with already low morale, there will be a deepened sense of resentment and victimhood about their treatment now and of cussedness later in response to future direction.

As I was writing this, the Government spun a yarn that fundamental reform is coming to the HSE in the form of a new board to take charge.

Vicky Phelan
Vicky Phelan

 

This is no reform at all. It is belated repair of wreckage seven years ago when the board was abolished.

It is a distraction from, and avoidance of, the central issue that rightly or wrongly the Department of Health, which effectively means the minister, is responsible for governance.

In blowing up what he could not rebuild, James Reilly said so. There was a gargantuan, schoolyard sort of boast that he would be responsible.

The responsibility of governance over the HSE is a responsibility not delivered on. The crude attempt to focus as much as possible on the HSE is further avoidance of responsibility by the Department which is ultimately wholly responsible.

The Taoiseach laid that bare on Monday when he said that he and Mr Harris “are finding out the facts... often at the same time as the media and the general public”. As a recent, former minister for health who left undisturbed the dysfunction which he found, that was pathos riven with irony.

There is a chance, however, he will get away with it. Play for time. Play as much of the game in front of the other goal.

Rely on the political gallery to follow the play away from causes towards events, and it should be ok. If past form is anything to go by, it probably will.

There is an alternative of course. It is to recognise that the Department of Health is not fit for purpose, structurally, administratively or intellectually.

Partly, that is because while some specific changes have taken place, the civil service remains fundamentally unreformed.

The “Minister and Secretaries” legislation is opacity central.

A modest proposal to have an outsider chair a board to which secretaries general would report was quashed. Instead, the Taoiseach chairs it — and it’s toothless anyway. So he is leading a system he is more the prisoner of, than in charge of. He told us as much on Monday, and I wasn’t surprised.

Specific steps that could be taken immediately, without recourse to legislation: The management committee of the Department of Health could immediately be chaired by a non-executive chairman, and joined by two or three non-executive directors.

Emma Mhic Mathúna.
Emma Mhic Mathúna.

 

This would not cut across the legislative responsibilities of the secretary general who is also the accounting officer.

The role would be confined to chairing meetings, overseeing the agenda and ensuring that aside from the existing reporting relationship of the secretary general to the minister, there is a separately supervised oversight of reporting to the management committee as a whole, and afterwards onwards up to the minister.

It would deeply discombobulate the civil service. But there must now be recognition of a fundamental divergence of interest between the State and the servants it employs.

One significant measure of that divergence is the continuing non-appointment of a director to lead the implementation of Sláintecare — the new strategy which, if implemented, may bring fundamental change.

It is apparently imminent, but it is also long-delayed. That’s telling. Because time itself is the single most potent instrument of administration.

More telling still is the decision, contrary to the recommendation of the all-party committee led by Róisín Shortall, to have the post situated in the Department of Health instead of the Department of the Taoiseach.

It’s comedy gold. It’s cynicism run riot. And it’s working to plan. Except that the plan is more about assuring continuity and protecting comfort zones, than delivering change.

Isn’t it extraordinary that a Taj Mahal-sized Strategic Communications Unit can be set up in the Department of the Taoiseach, complete with a readymade pre-interviewed director, but a year later nobody is in place to lead the agreed plan to change our healthcare system?

Taoiseach Leo Varadkar and Health Minister Simon Harris.
Taoiseach Leo Varadkar and Health Minister Simon Harris.

When she or he shortly arrives they will be outsourced to the department that has fundamentally failed in its primary duty, to inform that minister so that he can account to the legislature.

This is playing blind man’s buff with the largest, most complex organisation in the country and based on current plans, the game is set to continue.

None of this is new. It’s just newly highlighted. Ultimately it is not the responsibility or fault of the civil service.

They have simply become naturalised in shade, adverse to sunlight and fearful of withering if transplanted.

The responsibility is a systematic political failure, overseeing administrative failure. The risk of upsetting a relationship which is fundamentally one of dependence by the elected government, on the permanent government is too great.

The political cycle means timelines are too short. Having done little except survive in Health, having refused the responsibility again in sending the new Sláintecare head to that department, the Taoiseach can hardly be surprised if he and his minister “are finding out the facts ... often at the same time as the media and the general public”.


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