The Department

When I was growing up I used to enjoy watching shows on TV about biologists studying animal behaviour. Jane Goodall studying apes in the jungle. David Attenborough’s soothing timbre and impeccable upper crust British accent describing animal behaviours and what scientists think is going on. I always had this image in my head of animals noticing humans coming to study them and saying in their own language, “The humans are here. Quick, do something foolish and see what they make of it!” Scientists would spend hours watching intently, making lots of notes, trying to figure out what it meant when a bird did something or other. Much of what we know about the behaviour of all manner of species comes from such activities.

My perspective on The Department (of Health or whatever it is called in your jurisdiction) derives from the same kind of observations in the wild. I have never worked there, but I have interacted with it on so many levels over the years, formally and otherwise, that I have observations I offer for your consideration.

On one level, The Department is a buffer to help control the impulses of the folks who find themselves being called Minister. Since they don’t need to have any knowledge of the subject matter to get the job, some of them come to the office with some pretty … interesting perspectives. Someone has to make sure that those perspectives don’t do too much damage to the operations of The Department. On the one hand, the new person wants to show how essential (re-electable) they are by changing something. Salvation is at hand, they got here just in time to clean up the mess left by the other crowd, previous Minister, whatever came before. On the other hand, a Department as large and complex as Health can’t just pivot on the whim of a new Minister and someone has to temporize such urges. At its best, The Department serves to blunt the more impetuous goals of a new Minister (aren’t they always new to the job after all?).

Not every public servant wants the job for life, or sees advancement in The Department as their life goal. People come and go, but culture remains. It is is frighteningly common to find yourself at a meeting with The Department about a matter previously discussed, now with a different person across the table, since so-and-so has been reassigned or moved to other duties, and yet the conversation is essentially the same as at the last meeting on this topic.

Whenever a cluster of people are made to work together, a culture will develop. The cluster learns how they do things together, finding the best ways to respond to their circumstances. When a new person arrives, the culture is indoctrinated during the orientation, that is, “How we do things.”

The person representing The Department may change one meeting to the next, but the person sitting across the table comes with the same cultural predispositions as the one they replace. Over time, the culture can become the problem, as “How we do things” fails to keep up with “How we should be doing things.”

Culture can be overt or covert. I was at a meeting with people from the division of The Department that oversee the payment of doctors. We were discussing a new fee code (more anon). Once we had covered the how much and for what, the government side wanted to talk about oversight. When I asked what that meant, oversight, the response was that there had to be a system of oversight or doctors would “abuse” the new fee code. It was that word, “abuse,” that I noticed. I said something along the lines of, abuse, really? The person sitting across the table looked at me and matter-of-fact said, “Well, we all know you can’t trust doctors.”

The person who said this was no wizened veteran of The Department, speaking from years of experience. The person making this statement was much younger than I and had, I learned in the pre-meeting banter, only been with government for a couple of years. Only in The Department a matter of months. It was stated with authority but casually, like they had looked out the window and announced, “Oh, look, it’s raining.”

None of this person’s compatriots from government even looked up from their papers. No looks of surprise at the statement, no attempt to diffuse the dictum. The person was stating a fact that was simply the way things are as far as The Department is concerned.

That’s probably the only time the contempt has been that overt, but it doesn’t have to be to be felt. If you have ever walked into the wrong room for a meeting, the fact that none of the faces turning to look at you standing in the door are the people you expected to see is your first clue you are not where you should be. That, and the feeling you get when all those faces turn to look at you. No one has to say you aren’t where you should be. You don’t have to be told.

There was a time when doctors held positions of responsibility in hospital administrations; now, there might be Chief Medical Something-or-other, who gets trotted out to represent the administration to the doctors (it used to be the other way around). I used to joke that our local Department of Education had more doctors in it than the Department of Health did; the doctors in education were PhDs, the point was that at least Education new that you needed some subject matter experts in the department in order to make decisions appear credible.

Finally, The Department is not about delivering healthcare so much as shepherding the Departmental Budget. I have been at too many meetings about trying to do things differently that where the other side cut to the chase of, “How much is it going to cost?” and “Where is the money going to come from?” The Department’s role in government may, officially, be to administer the delivery of care, but the culture of The Department is to protect the budget from over-expenditure. Perhaps that’s part of the culture of The Department too, that career advancement comes through demonstrating an ability to keep to the budget and not allow a deficit. One suspects.

The seeds of this culture were planted decades ago and are deeply rooted.