It is a high-pressure department with a poor history of self-critical analysis that awaits rebirth, writes Muiris Houston
"As a defending counsel might put it, I express no opinion and any opinion I do express is all my own" - Dr Brendan Hensey (The Health Services of Ireland, 1959)
Writing the introduction to the 4th edition of his book in 1988, Dr Hensey, by then a retired secretary general of the Department of Health, looked back at the cautious words he had written in the original foreword and noted: "This cagey saver was made by a writer who was then a middle grade officer in the Department of Health, with hopes of rising higher. Now, at more than six years removed from the department, no such saver seems called for."
It is a reflection of how little the culture of the department has changed in the intervening years that few from the ranks of its civil servants were prepared to discuss, even off the record, the mood in the department or how people felt after the publication of the Travers report and the unprecedented removal of Michael Kelly as secretary general.
Informed observers have long described the department as a dysfunctional organisation. "Closeted", "sect-like" and "too ready to circle the wagons" are just some of the phrases used. "Its sect-like nature is reflected in its lack of openness and its ritualistic view of the outside world," was one observer's comment.
But perhaps the most telling description of negotiating with the Department of Health was the source who described its modus operandi as one of "plausible deniability".
This was an apparent game of cat and mouse in which support was offered, but only to the point where a proposal met with serious opposition. Is it therefore any wonder that a game of "pass the parcel" was played with the nursing home charges from 1976 until last year? Of course, the same analogy might well apply to the 16 ministers who have held the health brief since then.
The personal implications of the Travers process for Michael Kelly are widely regretted. No one questions his ability and many this week highlighted his key role in the implementation of performance management across the Civil Service. A successful stint as a "troubleshooting" civil servant in the Department of Justice is widely acknowledged. A prevailing view is that he was one of many who could have been caught with the ball behind their own try line after a five-metre scrum.
But Minister for Health Mary Harney was clear in her condemnation. From her perspective, the information originally furnished to her by the secretary general meant she "could no longer stand over statements I have made or gave to the House that the charges had been made 'in good faith'. . . This information can now be seen to have been inaccurate and incomplete in certain key respects."
But the Travers report is criticised by observers from across the health spectrum for not dealing in more depth with the role of previous secretaries general. Indeed, it is only by carefully reading an appendix to the document that one discovers that Jerry O'Dwyer and John Hurley, Michael Kelly's immediate predecessors, were interviewed. It would have been helpful if Mr Travers had more explicitly recorded the views of the secretaries general and other former senior departmental civil servants.
There is some acceptance within the department that the nursing home charge issue was handled badly. At 28 years' gestation it is certainly the most long-running, but it is by no means the only recent problem with roots traceable to the department.
From a taxpayer's point of view, the blood scandals and the undetected maladministration in the former Blood Transfusion Service Board was another expensive issue. The 2001 over-70s medical card initiative, while politically motivated, was never adequately costed. A pay deal for non-consultant hospital doctors, which famously resulted in a number of senior registrars being paid more than their consultant bosses, suggests a less than complete understanding of how hospital rotas worked.
And then there was the white elephant of the Eastern Regional Health Authority, which during its brief existence seemed to add to health service bureaucracy rather than improve the efficiency of front-line services.
Each of these events are classifiable as "critical incidents". For a commercial organisation, they would automatically trigger a critical incident review in which the mistakes would have been openly discussed and thrashed out and at the end of which organisational and other changes would be made. But in the Department of Health there is little, if any, evidence that such a culture of self-examination exists.
Instead, the organisation is defined by its defensive reactions. People "hunker down" and close ranks. Observers speak of whole sections disappearing into their bunkers. In this atmosphere, it is understandable that problems are readily labelled as "undealable with". For even the most dedicated civil servant, it is then but a short step to burn-out and cynicism, an end point that is unfair to both the individual and the department as a whole.
The 600 or so staff who work in the Department of Health deserve better than this. There is a consensus that the organisation is underpowered rather than understaffed. It needs to be reorganised and renourished in a way that acknowledges the unique demands that are placed on its civil servants. Many issues they face involve life and death. There is enormous pressure from outside groups, which bombard officials intensely with problems of high emotional content.
But others have escaped the unhealthy environs of Hawkins House to carve out blossoming careers. The most notable is Dermot McCarthy, the secretary general to the Government. Others include Dr Ruth Barrington, the chief executive of the Health Research Board, and Vincent Barton, a director of Prospectus Consulting and the author of the key 2003 report, Audit of Structures and Functions in the Health System.
So where to next for the Department of Health? And what specific initiatives might help it develop as a less dysfunctional organisation? Now that it has passed both the day-to-day management of the health service and the accounting officer function to the Health Service Executive there is no reason why a slimmed down Department of Health cannot emerge.
Travers has emphasised the critical changes that must take place to its Management Advisory Committee (MAC). This group of assistant secretaries, departmental directors and the chief medical officer has, in Travers' words, "been dysfunctional in many respects for some time". As well as recommending the appointment of external members to the group, he has suggested that members of the MAC be moved to different areas of responsibility "more frequently than has previously been the case". There is also a clear need to incentivise good performance, if leadership and responsibility are to become the hallmarks of a reborn department.
With the likelihood that a new secretary general and the new chief executive of the HSE will be appointed in tandem, an opportunity for cultural change at the top of health service administration beckons. There is one caveat, however: the new secretary general must be recruited from outside the Department of Health.
A move to a new building must be expedited. A number of sites are under active consideration and an early move from the "sick building" that is Hawkins House is essential if civil servants are to emerge from their bunkers.
Medical commentators have suggested that when the present chief medical officer's term of office expires, the office should be revamped by adopting the British model of appointing a CMO from outside the department. The British practice is to recruit a CMO from a cohort of doctors who have risen to high office at the medical coalface.
There is a need for health administrators to move from hospitals and the community into the Department of Health and for civil servants to undertake this journey in reverse. Standard practice in the Canadian health system, it would allow for a healthy cross-fertilisation of ideas and personnel.
New corporate support structures must ensure the department functions in an open and accountable way. Some time ago, the Association of Higher Civil and Public Servants suggested that government departments operate like commercial companies, with the minister acting as a chairman, the secretary general as a CEO and with other senior managers acting as the board of directors.
Brian Cowen famously described the Department of Health as "Angola" during his 2½-year term of office. Post-Travers, other unexploded landmines remain untouched in its filing cabinets. It is vital that a proper risk-assessment is now carried out so that this unexploded ordnance is professionally dealt with as part of the department's renaissance.
Muiris Houston is The Irish Times Medical Correspondent