7 The public service and health

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to the directions set by the government of the day’, but beyond that, it should be ‘innovative and imaginative’. The manner of giving advice should be ‘robust’, as secretaries must ensure that the minister is aware of all relevant facts about a policy and its likely impact, even if unfavourable, and of any difficulties, practical or political, it might present to officers implementing it (Shergold 2003 p 49). From this position the public service has been able to exert considerable influence over policy making. A health researcher found that bureaucrats were one of the policy ‘actors’ cited most frequently as influencing health policy, though less influential than the medical profession (Lewis 2005).

For years this tradition of giving ‘robust’ advice was underpinned by secure tenure for senior bureaucrats, making them relatively independent of political pressure. Secretaries, or heads of departments, the legendary ‘mandarins’, presided in the past over a ‘bureaucratic edifice’ which was the ‘permanent repository of wisdom on which its political masters of all colours could rely for frank and fearless advice’ (MacCallum 2004 p 28). For some, this tradition of ‘speaking truth to power’ remains the essence of the Westminster system, ‘the crucial element in advanced and rational governance …’ (Hennessy 1997 p 2).

Secretaries today are unlikely to address a prime minister with, ‘Now listen here …’ as one did in the 1960s (Weller 2001 p 90), but they are still obliged to make sure that a minister has all the facts, unwelcome or not. Advice should be politically non-partisan, but not politically naive, which demands a trusting and balanced relationship between ministers and secretaries, with the latter skilled at providing the evidence-based information essential for policy. Public service loyalty requires pointing out to a minister the potential unpopularity or adverse effects for the government of a particular policy (Walter 2006).

The public service is thus expected to be responsive to ministers’ wishes, whether officials agree with them or not: the ‘traditional public servant’ deals in a non-partisan way with both political parties (Grattan 2005). Any public service inclination towards independence is therefore constrained by the duty to follow, to respond actively to ministers’ directions, provided always that they are legal.

PUBLIC SERVANTS AND THE PUBLIC INTEREST

Ministers thus exercise, at least in theory, political control over their public servants, who are in turn accountable to them for departmental activities, reflecting secretaries’ further, sometimes overlooked, task as managers of often large public organisations. Political control is not, however, without its critics. Given the long tradition of public service professionalism, its requisite ability to serve all governments impartially, if public servants consider ministers, or their staff, are doing something questionable, perhaps they should go beyond immediate political authority to serve the ‘public interest’ through speaking out.

As citizens we expect public servants to put our interest before theirs when exercising their powers. The public service is not, after all, like the Australian Medical Association (AMA), which, however often its officers cite their devotion to the welfare of all citizens, is there in the end to defend and promote the sectional interests of medical practitioners. Rather, bureaucrats are ‘guardians of the public interest in protecting constitutional processes’, but have no authority to act as ‘superior arbiters’ in policy decisions – politicians define the public interest, and face electors’ judgment for doing so (Mulgan 2000 p 3).

SIZE AND STRUCTURE OF THE AUSTRALIAN PUBLIC SERVICE

Whether at federal, state or territory level, structure reflects the division of powers under the Australian Constitution, and in turn the priorities of the incumbent government. In the Australian public service (APS), departments embody primary functions, such as financial management, defence, immigration, welfare, health and education. There are the ‘central’ departments of Treasury, Finance and Administration, and Prime Minister and Cabinet, which tend to be more powerful than the ‘service’ or ‘spending’ departments, such as Health or Education. Some of these responsibilities appear also in the apparatus of state governments, especially health and education. Each APS department has a hierarchy, from secretaries down through the senior executive service and various classifications below, including training and graduate entry positions (Singleton et al. 2006).

The actual number of APS public servants depends on their being classified as staff under the Public Service Act 1999, as distinct from those outside the APS, but still in the public sector. Figure 7.1 shows the overall decline in APS numbers since 1980 and the recent rise to 146,000, with 5000 Medicare employees now included, and as a result of extra security measures (Trembath 2006). The APS is divided into 18 departments, or ministerial portfolios (see government website for details). Government functions, however, cannot be divided neatly into separate compartments: every significant policy issue crosses structural demarcations. Yet to the public, all services ‘must look like seamless delivery’ (Shergold 2003 p 50), so coordinating devices are essential, such as formal or ad hoc interdepartmental committees or less formal meetings between officials.

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Figure 7.1 Size of the Australian public service Sources: Singleton et al. 2006 p 241; Trembath 2006

The Department of Health and Ageing has nine sector divisions, including the Medical Benefits and Pharmaceutical Benefits divisions, four cross-portfolio divisions, and eight state and territory offices. The department also has responsibility for 56 agencies, which vary from those central to its work, such as Medibank Private and the National Health and Medical Research Council, to others which seem peripheral, such as the National Public Toilet Map.

After the 2004 election, the government created a Department of Human Services within the Department of Finance, to show the government’s commitment to oversee and improve the delivery of ‘important government services’. It brings together six agencies, including Medicare Australia (the former Health Insurance Commission) and Commonwealth Rehabilitation Services (Kerr 2005b), which both might seem more suitably housed in the health department.

Many of the 56 non-departmental organisations are statutory agencies with varying degrees of independence from ministerial (i.e. political) control – an example is the Australian Institute of Health and Welfare (AIHW), a government statutory authority within the department, but with some autonomy in carrying out its statutory obligations. Australian governments have long considered freedom from political interference desirable for public bodies such as the AIHW, with research and educational functions, or for regulatory bodies like the Aged Care Standards and Accreditation Agency. A different example is Medibank Private, a non-departmental organisation which is actually a government business enterprise (Singleton et al. 2006), a threatened species as a result of the privatisation of many such agencies.

State and territory health departments tend to look different, reflecting their more direct part in healthcare provision, especially acute hospital care. Queensland Health, for example, has six ‘portfolio’ type divisions, including a ‘Reform and Development’ division as a response to the recent inquiry into Queensland public hospitals (see Ch 15), while the state as a whole, like New South Wales, is divided into similar regionally based area health services. These arrangements illustrate the difficulty of organising a complex system like healthcare, in that governments need nation- or state-wide, as well as area-based, services.

PUBLIC SERVICE REFORM

Since the relatively stable period of the ‘old’ APS up to the 1970s, the bureaucracy has undergone considerable change. As Kingdon (1984 p 115) says, a condition becomes a problem when we decide to do something about it and the ‘problem’ in this case was perceived as the powerful position of secretaries, whom some ministers in the 1970s considered too dominant and not sufficiently responsive to politicians’ wishes. By the 1980s, a new Labor government was determined to make the APS more responsive to ministers and to the public (Weller 2001). Changes under the 1984 Reform Act made it easier for staff to enter from outside, rather than rising from the lower levels, and allowed for the removal of secretaries. Major aims included improving responsiveness, reducing the cost of government operations (through attention to results and cost effectiveness), enhancing delegation and devolution of authority, and aiming at more efficiency and flexibility, with a more commercial approach (Holmes & Wileman 1997 p 14). The APS, lagging behind other countries in the early 1980s, made considerable reform progress in the next decade, reforms extended and deepened under the Howard (Coalition) government and consolidated in the Public Service Act (Halligan 2005b).

The idea of a career public service, with its tenured ‘mandarins’ at the top as the sole source of ministerial advice and information, has been transformed. Secretaries moved to contract appointment from 1994, compensated by higher pay (Weller 2001). Former central control of budgets by Treasury, and of employment and working conditions under the Public Service Board (abolished 1987) vanished, these functions delegated to departments, whose senior officials now managed staffing and budgets.

External reasons added to the drive for change, especially financial constraints, and awareness of similar changes occurring in Britain and the US. A department head saw the pressure for change coming from, first, rising public expectations for more varied, complex and better quality services (with lower taxes); and second, globalisation and new technology affecting Australia’s ability to compete in world markets (Hawke 2002). All helped gain acceptance for the shift towards what became known as ‘new public management’ (NPM) or ‘managerialism’, based on three central tenets:

‘Privatisation’ accompanied NPM – not just government selling public assets such as Telstra, but also the private sector replacing government in publicly funded service provision (‘outsourcing’), or government withdrawing from such provision (Aulich 2005 pp 58–9).

NPM also implied the public sector adopting private sector methods of management, including market mechanisms and some competitive practices. Agencies now emphasised results, or ‘output’ and ‘outcomes’, over bureaucratic rule-dictated processes, and used ‘explicit standards and measures of performance’ (Zifcak 1997 p 107; Singleton et al. 2006). The 1999 reforms added the premise that the APS would ‘benchmark’ its performance against private sector ‘best practice’, improve financial management, and use such arrangements as performance indicators, competitive tendering and contracting out ‘to improve accountability, quality and cost-effectiveness’. The Act also included for the first time a statement of values and a code of conduct, including extra protection for ‘whistleblowers’ (Singleton et al. 2006 pp 241–3, 254).

By the mid-1990s, the operative government model viewed the public sector as an adjunct to the private, and depicted the public service as less influential than, and subservient to, the private sector. The Howard Government, convinced of private sector pre-eminence, achieved an ‘overall repositioning’ of the public sector, in line with its vision of the public service as a business, operating in circumstances of competition and judged by results (Halligan 2005a, b). The public service, a secretary considered, must be ‘efficient and flexible’, with staff able to move around without the old prescriptive rules and detailed regulations (Moore-Wilton 2000).

The effects of reform

As Halligan (2005b) notes, these major reforms have:

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