Brendan Drumm rightly described the latest scandal of misdiagnosed cancers as "appalling". But to understand the inability of the Health Service Executive to get to grips with the services it runs, you could do worse than look at the report of the Review Body on Higher Remuneration, writes Fintan O'Toole
In an extraordinary passage, it considers pay levels for managers in the HSE - the standing army of national directors, assistant national directors, hospital network managers, directors of regional health offices and managers of local health offices. And it says, in effect, that the review body had a hard time working out what they should be paid because it couldn't quite figure out what precisely many of them do. Welcome to Ireland, Mr Kafka.
Referring to an interim report on HSE managers' pay in December 2005, the review body states that "some of the jobs we examined in 2005 were clearly in a transitional state and the roles had not been fully developed. In those cases, it seemed to us that there was a lack of clarity about the future content of jobs. The absence of stability created difficulties for us in evaluating the posts covered by our review. We accept that there has been progress since our review in 2005 and that the situation is somewhat more stable than the one that applied in 2005. In our view this stability is more evident in the posts at national director level than at the level of assistant national director.
"In the case of posts below the level of national director, in particular, we consider that there is still some lack of clarity about the precise direction and reporting relationships of some of the jobs we examined and this made it difficult to evaluate them. We concluded that there is still an element of evolution about some of the management posts. At this stage in the development of the HSE we would have expected to find a clearer and more stable organisation structure. We would urge the management of the HSE to address this issue as a matter of urgency."
Translated from the clipped bureaucratese of the report, what this means is that, almost three years after the HSE was established, an official body still can't quite get a fix on what many of its highly-paid managers actually do. The suggestion is not, of course, that the people in these jobs are lazy or useless. It is, rather, that the jobs themselves are so fuzzy, and the relationships between them so ill-defined, that it is very difficult for any outside observer to understand who is responsible for what. Given the general lack of rigour applied by the review body, this is really saying something.
In a functioning democracy, this would be a big issue. The HSE is, for the citizens of this State, literally a matter of life and death. Its decisions change the lives of tens of thousands of people for good or ill. In any given month, 100,000 people are treated at one of the HSE-funded public hospitals. Almost 400,000 people with disabilities, and their carers, have to interact regularly with HSE-funded services. The HSE itself employs 130,000 people directly or indirectly, and spends €15 billion of public money a year. If "the precise direction and reporting relationships" of some of its most senior management roles is so unclear, the level of accountability for the choices it makes can only be miserable.
And like every other disaster in the public realm, this one was both predictable and predicted. On December 14th, 2004, for example, I wrote here: "Mired in confusion, riddled with uncertainties and lacking any notion of democratic accountability, the process of establishing the HSE is a disgrace." I pointed to the chaos and confusion of the Dáil debate on the legislation setting up the HSE and called for a delay in the establishment of the agency to allow for the creation of clear, accountable structures.
Since then, the HSE has become a battery farm of bureaucracy. It just can't help creating more and more middle managers, whose numbers have grown by 37 per cent, from 521 to 713 between late 2005 and June 2007, even while front-line services are being cut. And while this is happening, the Government that created it throws up its hands in mock-horror and disavows all responsibility. Dr Frankenstein hunted down the monster he created, but the Government wrings its hands and occasionally pleads with the monster to control himself. Éamon Ó Cuív whinges that he "just cannot make head nor tail of the HSE as an organisation", as if he was on a trip to Antarctica when it was established.
Mary Harney told the Dáil last month that "I share the concerns about the growth" in middle-management posts at the HSE. "As part of a new employment control framework introduced in December 2006, the HSE is now required to get my Department's approval for the filling of posts at grade eight or above. Despite the controls that are in place now, the numbers are running ahead of expectations."
So her department has approved a growth in middle-management numbers beyond "expectations" but she doesn't approve of it. Like every other mess, it just happened.