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Challenge and Change in the Irish Public Service in 2010

Thank you for your invitation here this morning. I’d like to begin by reflecting on what I have observed since the economic downturn took hold and the reality of it began to settle in our collective national consciousness.

At one level it reminded me of an evening at home some years ago when there was a prolonged power cut locally. We lit candles, gathered round the fire, and starved of TV, DVD, Twitter, Internet, Facebook, Bebo, Youtube et al, the seven of us actually began to talk to each to each other.

And that’s precisely what’s begun to happen here. Starved of the diversions of affluence, shocked by the downturn fallout, we have all begun to talk to each other again, to debate, to take a breath, glance around, and strike out for a redemptive New Ireland.

It’s taken many forms, whether at Farmleigh with the musings of the selected great and good, or on Morning Ireland all last week with its five day discussion on the role and potential of the arts, or through President and Doctor McAleeses’s Your Country Your Call initiative, or through the current Irish Times series on a new republic. There is, I believe, a collective recognition, that we need to find new ways of being ourselves, of organising ourselves, of managing our affairs in a way that will not deal just with our current problems but which will transform the manner in which we conduct ourselves well into the future. To paraphrase a currently fashionable saying, no good crisis should go to waste.

It is in the spirit then of this Irish perestroika that I make my contribution this morning.

The process of public service modernisation and reform has been underway in Ireland for several years now. I suspect there is a tendency to see this process as a technical business, primarily, expressed in terms of systems, efficiencies, outcomes, value for money and so on. The impetus for public service reform reflects a dissatisfaction with how many public sector monopolies performed in the past as well as a perception that, left to itself, the public sector is not capable of raising its game. Into this mix also we must recognise that there are pressures for change arising from our membership of the EU as well as good old-fashioned ideological and political considerations. However, there is in all of this a wider truth; one which, I feel, has not been recognised and debated to anything like the extent it should. This truth is that changes in the structures for delivering public services, or in the manner of delivering services, almost invariably have impacts which extend far beyond the realm of the technical. In fact, such changes can impact on how we see ourselves as a society, on how social solidarity is expressed and supported (or, indeed, undermined) and on the strength of that social cohesion which is necessary to the survival of civilised living. All of this, of course, is about how we choose to govern ourselves.

It seems to me that there is a demand now to change how we govern ourselves and to act on the basis of values which will endure. I think we can all agree that people generally want to live in a society based on the values of fairness, equal opportunity, respect for human dignity, respect for the law; a society that is well governed. This current crisis presents an opportunity to put right many of the unsavoury practices which we have indulged in over the past decade or so and to create a society we can be proud to live in. It seems to me that what people are seeking now is not some Utopia but a set of practical arrangements for government, based on clear values, which will be sufficiently robust to accommodate the inevitable vagaries of human nature.

Many people have already suffered a great deal in the past 18 months or so; standards of living have dropped across the board. For some, the price of our national madness is higher than for others. We know that over several more years there is likely to be a further decline in living standards generally. To get through this very difficult period without significant unrest will require a degree of social cohesion and national solidarity such as we have not seen for a very long time.

It seems to me that the decisions we take now about the structures for public service delivery, and about how services will be delivered, will have a crucial bearing on whether or not we can create and sustain the level of social cohesion that is so necessary. Fundamental to achieving this social cohesion will be an honest appraisal of the role of public services and an equally honest assessment of the structures for service delivery.

I will return to these issues shortly but, first, let me say some things arising from my own experience. As Ombudsman, I deal with complaints about Government Departments, local authorities, the HSE and An Post. With the creation of a statutory complaints mechanism with the HSE some years ago my remit also expanded much more widely into the health and social care area and particularly into hospitals.

The trickle down effect of the downturn naturally impacts on my Office and as I begin to deal with many recession cued complaints, I am forced to consider the wider issues around them and not just the immediate process elements of an individual complaint. The recession has led to changes in the numbers and in the nature of the complaints I receive. We are seeing more complaints about social welfare and health service benefits and treatment and fewer in relation to planning and development. And while social welfare and health service complaints have increased – up by 15.5% in 2009, as compared to 2008 – I do not see this increase as necessarily reflecting on the quality of service provided by the public bodies concerned. Rather it is first and foremost a consequence of the very significant increase in transactions within these services.

Indeed, it is clear over the last 18 months how much more dependent we have become on public services, whether through assistance for the newly unemployed, access to public healthcare for those who can no longer afford private health insurance premia, rent allowances for those who can’t afford to keep up their mortgages repayments and are forced to sell, children returning to the state education system because their parents can no longer afford private school fees.

The fact that people who find themselves in these difficulties turn to the State for support says a great deal about what people, fundamentally, expect of the State. How the State responds to these people will determine, to a very major extent, the kind of State which will emerge over the next few years.

And this, I believe, is the critical point: that we need to make decisions about the delivery of public services with an eye, primarily, to whether the structures and the manner of delivery will promote social cohesion and solidarity or whether, alternatively, they will have the consequence of inhibiting the development of social cohesion or, indeed, of actively working against it. Furthermore, it seems to me that the language we use in discussing public service delivery needs to move away from “management speak” and towards a vocabulary that emphasises shared public responsibilities and rights. I am not suggesting that business planning, management development and hard output targets are unnecessary. Certainly they are necessary – but, in the public service context, they need to be seen as aids to a process rather than the heart of that process. In recent years the language of public service reform has been taken from the world of business. There is a validity in this but only up to a point. Ultimately, business is business and it is measured in terms of profit. Public service is quite different: it is the expression of a shared vision of society, of a common purpose, of a recognition of mutual dependence, of sharing the goods and the burdens of this life. Public service has a heavy ethical dimension. It is not motivated by profit. Therefore, while we would like our public services to work efficiently and cost effectively, we absolutely require that they work in a manner which supports and promotes social cohesion and solidarity.

Now, lest all of this sounds somewhat theoretical and “airy fairy”, let me turn to some real life examples of how this manifests itself in practice. Of all the public services, the health service area is the one where we can see, perhaps most clearly, how structures and delivery methods impact most directly on individuals. It is also an area in which my Office has a great deal of experience, over many years, both on issues to do with entitlement, with administration and, more recently, on matters of actual care and treatment.

If people experience the public health system as being unfair and inequitable this inevitably tells them that the State does not care. No amount of fine talk about the virtues of solidarity and social cohesion will make the slightest impression on anyone whose real life experience is that the public health system is constructed on inequality. I appreciate that everything to do with healthcare is highly political; but as someone charged with dealing with complaints about public healthcare I am bound to reflect what I see, day in and day out, in dealing with these complaints. While many people have very positive experiences of the public health system, it is equally true that very many do not. A major inequality arises from the continued existence of a dual and interdependent public/private health system. The case of the late Suzy Long (who did not have a colonoscopy provided in a reasonable time and died subsequently) has become emblematic of how this dual system can prove so unfair.

I would like now to mention a particular case which my Office investigated recently. My investigation findings in this case, for the most part, concern process issues. And I do want to stress that getting the process right - having appropriate communications protocols and good administrative practices, for example - will always remain central to good public administration. But, while it was not something I was in a position to make a finding on, this case also raises an issue about the nature of our public/private healthcare system.

This case concerns a woman, a public patient, who was suffering from a chronic condition which had possible respiratory and cardiac implications. Her condition deteriorated and her GP sent her for assessment to a local hospital. Tests were done subsequently, in a different hospital, and the results which showed significant abnormalities were sent by ordinary post to the referring Consultant in the local hospital. Some days later, as the test results continued to sit in the Consultant's cubby-hole in the public patients' office, the woman died suddenly. Now, at this point I should say that there is no evidence whatsoever that the death would have been prevented had the test results been attended to speedily. But the distress caused to her husband and children, by the knowledge that abnormal results had not been opened and reviewed, can be imagined. This is something all of us here can empathise with.

My investigation took the form of an administrative audit, tracking the trail of the test results, interviewing relevant people including the Consultant involved and the staff who provided secretarial assistance to consultants in the course of their public work. My recommendations are around the improvement of that process, asking the Hospital to ensure that systems are in place that will ensure for the future that test results will be attended to in an appropriate and timely fashion. Patients and their families deserve to know that harm will not be done because of inadequate arrangements for ensuring important test results are seen as speedily as possible by the relevant consultant.

During the course of the investigation, it appeared that arrangements for dealing with the test results of private patients operated somewhat differently to those of public patients. In the case of a public patient, I was told by the Hospital that test results were sent to the public patients' office and that the onus was on the consultants to collect them. Occasionally, when letters were stacking up, a member of the secretarial staff might alert a consultant to this fact; but there was no system in place to ensure that this happened. In contrast, it was clear that private patients had their test results opened by the particular consultant’s private secretary, on a daily basis. In this way, the private secretary was in a position immediately to draw the attention of the consultant to any results which might be a cause of concern.

Unusually, the Consultant involved in this case disputed the Hospital's account of arrangements for dealing with test results; he maintained that all test results, whether for public or private patients, went to his private office. This in itself raises a great many questions about the propriety, if it is the case, of a private employee apparently dealing with the medical records of public patients. It is something I dealt with in my recommendations to the Health Service Executive. In any event, I was unable to resolve this dispute between the Consultant and the Hospital as to the actual arrangements for dealing with the test results of public patients; but I did establish as a fact that, in the case of this particular public patient, her abnormal test results did not go the consultant's private office; rather, they lay unopened for almost two weeks in the Hospital's public patient office. When the test results were opened, which happened because the GP made enquiries, the patient had been dead for ten days.

So, through my recommendations, what I was doing essentially was identifying faults and trying to patch up a creaky public system, to have it match the speedier and undoubtedly safer system in use in the Hospital in the case of test results for private patients.I was attempting to match the public experience with the private one so that no public patient would suffer a lesser outcome by virtue of the fact that his or her test results were handled differently.

Naturally, the recent Tallaght Hospital case, involving thousands of unopened referral letters, and unread X Rays, has brought this issue once again to the forefront of public consciousness. An investigation is to be carried out into what happened, chaired by the former Northern Ireland Ombudsman, Maurice Hayes. As I understand it, there is not yet any hard information regarding the breakdown of the unopened letters, and unreported X Rays, as between public and private patients. The media, I note, have been trying to get answers to that question but so far the hospital has not supplied them. No doubt, this will emerge in the course of the enquiry, but based on my own experience, in the case I have just outlined, and assuming that it wasn’t unique to that hospital, I would be surprised if the result didn’t show that the private patients were more likely to have had their referrals attended to and their X Rays reported on.

I realise that the private versus public healthcare debate is both political and ideological. We need look no further than the United States to see how true this observation is. While not claiming to be an expert on healthcare systems internationally, it does seem to me that some of our European neighbours manage to operate public healthcare arrangements which combine quality of care and equality of access with reasonably strong public support and acceptance.

Ideally, the delivery of healthcare should be neither a matter of ideology nor of politics. Rather, in a small country like ours with a largely Christian ethos of care and compassion for all, regardless of means, the health debate should be firmly grounded on the twin pillars of pragmatism and of a recognition of the wider societal impact of how key public services are structured and delivered. Where the public see that the State's healthcare arrangements are fair and equitable, based on need and on citizenship rather than on the ability to pay, then such arrangements support and promote social cohesion.

And if that sounds pious, it isn’t meant to be. Delivering high quality healthcare to every member of the population that needs it, isn’t just a piety, it’s also a pragmatic response which can only result in wins all round. Let’s say for example, that the systematic failure to deal with public patients' test results in a hospital, any hospital, led to, as it must, an increased number of delayed diagnoses for people with serious, costly illnesses. Treatment at this stage inevitably involves a greater drain on public money and resources and thus greater pressure on the country’s finances. The securing of a fit for purpose healthcare system for all isn’t just about doing good, or being mindful of the beatitudes, it is about ensuring a cost efficient service which, in guarding the public's health, also guards the public purse. And that surely, must also be to the forefront of the thinking of everyone gathered in this room today.

But to go back to my opening comments about the beginning of a great national debate on our country’s future, there has also been an increasing scanning of the international horizon, whether it be in relation to the banks and which country managed their system better or in relation to health and educational outcomes. Instead of gazing at our own navels, we are seeing where best practice appears internationally and whether we can adapt accordingly.

A very interesting contribution to this debate came last year in the form of a new book by two British-based epidemiologists, Richard Wilkinson and Kate Pickett, called 'The Spirit Level - Why Equality is Better for Everyone'. I put forward their thesis lightly, simply in the spirit of promoting constructive debate.

The basic thesis in the book is that better outcomes in health and education are governed not by how wealthy a society is – above a certain basic level - but how equal it is, in other words by the size of the income gap between the richest and the poorest people in that country.

This thesis derived from two decades of research and is based on statistics generated by the countries themselves, which are included in the study, and by UN statistics and measures of inequality. It opens with a table showing the breakdown of the income gap as between various countries in the developed world.

In that table, the countries with the highest gap between richest and poorest are Singapore, the USA, Portugal, the UK, Australia and New Zealand. Those with the smallest income gap are Japan, Finland, Norway, Sweden, and Denmark. Out of 23 countries, Ireland appears in 14th place, that is, nine other countries have larger income gaps than we do. I should say at this point, that the book emerged before the downturn, so I’m not sure how radical a change the sharp decline in bankers’ incomes has had on the gap.

The book takes the income gap comparison as its bedrock statistic and then explores outcomes in those countries in relation to health, education etc. Time and again, the countries line up in virtually the exact same order as they lined up in on the income gap table. In other words, poorer outcomes in those areas for the countries with the biggest income gap, and vice versa. The country’s wealth – beyond a certain point – is virtually irrelevant as to how the bulk of the populace do. The book also makes the claim, again underpinned statistically, that even the wealthiest do better in more egalitarian societies.

A few examples: the use of illegal drugs is more common in more unequal countries. It is lowest in Japan, Finland and Sweden, highest in the UK and the USA. Ireland is slightly above the mid line, again in line with its income distribution levels.

More adults are obese in more unequal countries. In the USA , just over 30 percent of adults are obese - a level more than twelve times higher than Japan. Norway and Sweden have relatively low levels of obesity and Ireland again is slightly above the mid line. The same patterns broadly emerge for childhood obesity.

The maths and literacy scores of 15-year-olds are lower in more unequal countries. Highest attainment is Finland, while Ireland is above the mid line in a good way in this area.

The lowest teenage birth rates are found in Japan, Sweden, the Netherlands and Denmark; the highest in the US by quite some stretch, with the UK and New Zealand also quite a bit above the mid line. Ireland is also above the mid line in this regard. Similar results emerge when it comes to mental health, the prevalence of chronic illness, mortality rates, and so on.

The authors note: “One of the points which emerges is a tendency of some countries to do well on just about everything and others to do badly. You can predict a country’s performance on one outcome with knowledge of others. If – for instance – a country does badly on health, you can predict with some confidence that it will also imprison a large proportion of its population, have more teenage pregnancies, lower literacy scores, more obesity, worse mental health and so on. Inequality seems to make countries socially dysfunctional, across a wide range of outcomes.”

The book is not prescriptive in relation to how a country can achieve smaller income gaps and greater equality; it notes for example similar positive outcomes in two radically different countries, Japan and Sweden, noting that Sweden flattens the gap by way of a redistributive tax system, while Japan flattens income long before the tax take. All in all, the insights are worth considering as we attempt to fashion our public services in a way that benefits all of us who live on this island.

Returning now to my own work as Ombudsman, I mentioned earlier that complaint numbers have increased - up by 15.5% in 2009 as against 2008. While it is not easy to identify any single trend running through the complaints I receive, I do detect that the values of fairness and upholding the common good, are to some extent under threat. It is not by any means that public servants set out to be deliberately unfair or discriminatory in their approach to service delivery. They do not, and I do acknowledge that the vast majority of transactions between public bodies and their clients are carried out in a proper, fair and impartial manner. But particularly in these straitened times, public servants can struggle to manage the competing interests of reduced budgets and increased demands for services. Inevitably, it is the budgetary constraints that win out. For example, and as I have mentioned elsewhere recently, over the years my Office has seen instances where public bodies have introduced upper age limits to ration grants even though they had no legal authority to do so. We have seen homeless single people refused consideration for housing on the grounds of limited housing stock and the more pressing needs of homeless family units. It may seem reasonable to create such priorities but not when the governing legislation does not, in fact, authorise a public servant to ration resources in this way.

Another area of concern arises from privatisation of public services and its effect on core public service values. I have already witnessed these effects in the local authority service where the privatisation of waste collection services has made it increasingly difficult for local authorities to administer waste waiver schemes in respect of the changes payable by low-income households. While many local authorities are very conscious of their social obligations in this regard, a small number seem to be moving towards the rules of the market place stating that they are in competition with private operators and for this reason are unwilling or unable to introduce a waiver scheme for the private operators. I carried out an "own initiative" investigation of this issue, which highlighted the need for the Department of the Environment, Heritage and Local Government and local authorities to take account of their social obligations in the design and delivery of waste management services. My report, which I published last year, is on my website.

This a link to the Ombudman's Investigation into the operation by Local Authorities of Waiver Schemes for Refuse Collection Charges

I'd like to conclude by reflecting on the recent debacle in relation to my Lost at Sea Report - the treatment of which directly threatened the future effectiveness of my Office and the ability of thousands of ordinary people to achieve fair and proper outcomes for their complaints against public bodies. I continue to hope that the matter will be resolved satisfactorily but I also believe that the strength of the Office needs to be enhanced to guard against future acts such as that we have witnessed.

What I am talking about is the conferring of constitutional status on the Office - a status which the Office of the Comptroller and Auditor General already enjoys. Our system of administration has traditionally placed more emphasis on financial accountability - the bailiwick of the Comptroller and Auditor General - and has somewhat undervalued the importance of administrative accountability - my own bailiwick. The Accounting Officer function and the role of the Public Accounts Committee - which is by far the most powerful and longest established committee in Dáil Éireann - underlines my point. As an aside, and in the light of my own experience with my Lost at Sea Report, it is impossible to envisage the Dáil voting not to refer to the Public Accounts Committee a financial irregularity uncovered by the Comptroller and Auditor General.

While the Office of the Ombudsman does not enjoy constitutional status, it was recommended, as far back as 1996 by an independent Review Group on the Constitution, chaired by TK Whitaker, which reported as follows,

"It is clear that in recent years a consensus has emerged in the two Houses of the Oireachtas about the desirability of not only maintaining the institution of Ombudsman but of strengthening and developing it. The role of the Office will become all the more necessary if devolution and delegation within the public service develops as envisaged. A constitutional guarantee for this independence would reinforce freedom from conflict of interest, from deference to the executive, from influence by special interest groups, and it would support the freedom to assemble facts and reach independent and impartial conclusions."

Subsequently, an All-Party Oireachtas Committee on the Constitution in its first Progress Report (April 1997), endorsed the Review Group's recommendations and recommended a specific text for inclusion in the Constitution. For reasons that are not clear to me, the Committee's recommendation was not implemented but at least the importance of maintaining and strengthening the Ombudsman's Office has been clearly recognised. In 2004, on the occasion of the Office's 20th anniversary, I called on the Government to initiate the process of conferring constitutional status on the Office. I pointed out that such status was very much the norm in other modern democracies. Now, in the aftermath of my Lost at Sea Report, I do feel the matter has taken on a new relevance. Constitutional status would further enhance the independence of the Office of the Ombudsman, not for its own sake, but to support it in its work on behalf of the many thousands of people who come to it for assistance in these challenging times.

In conclusion, though, I would like to return to the central important point which we should all bear in mind in considering the challenges and changes facing our public service. How we structure public services, and how services are delivered, have implications for us as a society; implications which influence the kind of society we achieve. If we want to promote a society which is fair, tolerant, open, a society which can stand together to face our current difficulties, we need to ensure that we design and operate our public services in a manner which will support these objectives.

Thank you.