This is a question well known to politics students that is often asked in terms of who really wields the power in State and society.
It's a very good question.
Revelations in recent days about generous top-up pay to senior staff in hospitals and other health agencies raise the question of who really oversees the many institutions in our health service.
Is it Government, acting on behalf of the public which funds these agencies, or largely self-regulating and unaccountable elites within these organisations?
In recent days we have seen media accounts about 'top-up' payments to senior hospital and other health service staff which are in breach of official Department of Health official pay policy.
The extra payments controversy has shown a very basic lack of accountability and transparency among voluntary health agencies who rely on the public, through tax revenue or voluntary fundraising , to fund their services.
Some of these additional payments appear to have come from non-HSE sources funded by the institutions themselves through 'private sources'. It has yet to be clarified to what extent money donated, for example, to high-profile fundraising campaigns for some organisations, has been used to fund extra pay for senior staff.
Some institutions have admitted that they are in breach of official Government pay policy in making extra payments.
While few would argue that health managers should not be reasonably paid for their often onerous duties, many would feel that the pay rates quoted in media reports are excessive, especially in the current still-challenging economic climate.
The public will also be concerned about the level of accountability displayed by these health agencies in terms of their breach of Government pay policy.
People would also query why these extra payments are being made at a time when more than one fifth of the health budget has been cut, often from essential services, over the past five years, with at least €1 billion more due to be lopped off next year.
The public would also have been forgiven for believing that these extra payments were a thing of the past.
Dublin's Tallaght Hospital said it ceased top-up payments to senior staff in 2010, after it was revealed that around €700,000 was paid out from public funds to five senior staff members there between 2005 and 2010.
irishhealth.com revealed earlier this year that a review of these payments could find no documentary eviudence of a rationale or approval process for them.
It appears however, that even after these Tallaght payments stopped, the remuneration bonanza continued in other health agencies, with the same apparent lack of accountability.
And the revelations about extra pay for senior health staff have not come about following some Damascene conversion to full transparency and accountability on the part of health agencies.
No, these revelations have come about thorough media digging and through probing by the health authorities.
The Tallaght top-up pay scandal, it should be remembered, was a by-product revelation from a HIQA probe into deficits in the hospital's emergency department service.
Even after the latest drip-feed of information about extra pay, we still do not have a complete picture of the public pay policy compliance or otherwise in health agencies nationally.
Some agencies appear to have been sparing in the information they have divulged. A full picture is not yet available of the rationale or approval process for many payments.
This lack of accountability is worrying, and it is right for Health Minister James Reilly to be concerned about it.
However, it is Minister Reilly who is is planning to give hospitals perhaps even greater independence than they currently enjoy, under his plans to set up first hospital groups, then independent hospital trusts.
He would need to tread very carefully here. The level of accountability of some hospitals is in some cases suspect to say the least. Accountability could be diluted even further if hospitals are to get greater independence of action.
The system of hospital groups/trusts will need to be very strictly regulated in terms of both financial and quality and safety management.
And it should be pointed out that we have already seen major problems with safety and financial management with hospital trusts established in the UK.
Ultimately, it should be the State and the people who govern the health service they pay for. People deserve to be fully told what is going on behind closed doors in our health institutions.
Extra pay bonanza for hospital chiefs
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