Between 1660 and 1782, the departmental structure of the British government was easily grasped. There was a Northern Department that dealt with northern Europe and a Southern Department which dealt with… well I’m sure you can guess. That, more or less, was it. Various matters of domestic policy were divvied up between the two departments and administered alongside their respective responsibilities for foreign policy.
In the latter part of the 18th century, someone had a brainwave – it might just make more sense to have one department dealing with foreign policy and the other with domestic policy. So in 1782, the Northern Department became the Foreign Office and the Southern Department became the Home Office. In the course of the 19th and 20th centuries, as governments got bigger and provided more public services and a social security system, various specialist departments for heath, education, housing etc were split off from the Home Office – meaning that most Whitehall departments today are lineal descendants of the old Southern Department.
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Multiple ministries with subject-specific responsibilities are the obvious way to organise a modern national government. There is a cost, however. Separate, specialised ministries beget separate, specialised bureaucracies to administer and deliver the public services for which the most senior minister in each department is ultimately responsible.
The trouble is that public services are delivered to real people in real places, whose real needs are not separate. Rather, individuals and families have problems that can only be effectively dealt with together.
Writing for the New York Times, Dhruv Khullar provides a sombre example:
“Americans with depression, bipolar disorder or other serious mental illnesses die 15 to 30 years younger than those without mental illness — a disparity larger than for race, ethnicity, geography or socioeconomic status. It’s a gap, unlike many others, that has been growing…”
The reasons for this gap aren’t necessarily what you might expect:
“We may assume that people with mental health problems die of “unnatural causes” like suicide, overdoses and accidents, but they’re much more likely to die of the same things as everyone else: cancer, heart disease, stroke, diabetes and respiratory problems. Those with serious mental illness are more likely to struggle with homelessness, poverty and social isolation. They have higher rates of obesity, physical inactivity and tobacco use. Nearly half don’t receive treatment, and for those who do, there’s often a long delay.”
To differing extents, we have specialised healthcare services to administer specific treatments for specific physical and mental health conditions. These are, in most cases, more effective now than at any time in human history. But when it comes to helping the person, I wonder how much progress we’ve made:
“After decades of fragmenting medicine into specialties and subspecialties, it’s perhaps not surprising that a siloed system often fails those in need of whole-person care.”
This isn’t just about medicine, of course. Other public services – from social housing providers to the police – may end up dealing with the same individuals, but each only in respect to their immediate responsibilities.
Khullar reports on some innovative projects whose purpose is to help the whole person, not just one of their problems. But why are such schemes the exception and not the norm?
Though politicians like to talk about ‘joined-up government’ and ‘integrated public services’, they forget that public services already overlap – at the level of the person and the place. Given the opportunity to do so, frontline public service professionals from different services, who have practical experience of the people they help and the places they work, have every reason to come together to exchange information and find solutions.
The trouble though is that they are subject to separate bureaucracies, with chains of command stretching away to distant centres of power, where policy decisions and resource deployments are separately and distantly made.
Even when governments make an effort to coordinate public services – as in the case of Britain’s Troubled Families Programme – it is done from the top of the bureaucratic hierarchies, not at the frontline. No wonder such programmes fail.
It is not the centres of power that need to be joined-up, but the localities of experience.