If You Were Director HHS

What would you do if you were Director of Health and Human Services?

Let’s imagine you’re an accomplished administrative professional with education and experience in the delivery of health, mental health, and social services. You have literally thousands of hours of education and continuing education, all with the wellbeing of the community at heart.

The one thing all these years of education and experience don’t prepare you for is a Board of Supervisors who doesn’t want you to do your best work. They are doubting your leadership, questioning your judgement on staffing levels, complaining about the abundance of services you’re bringing and they’re being goaded by the press and a few vocal citizens to crash Child Welfare Services.

Only one person knows how it is to walk in Director of Health and Human Services Dr. Robert’s shoes, and she typically doesn’t complain much. We can speculate on what would we do; what do we want her to do.

The Scope of the Problem

Currently, Health and Human Services is taking flack on a couple of fronts.

The Messenger has registered the shock most people do when confronted with CWS. The Mess attributes the problem to one social worker and a flaccid court system. The Prospect complains of a system that has over-extended its authority and inflicts iatrogenic  trauma on its clients. County Supervisor Lee Adams has expressed grave concerns about the growth of HHS staff and the ratio of workers to county residents, and of wasted money. Other supervisors have manifest doubts about the Teen Center (you’d disappoint Ashely Cabrera?), and particularly about placing it in the Loyalton Jr. High, which they feel might be sound, but still isn’t a sound investment. The controversy posted in the media and expressed by the Board has empowered citizens who have been handled roughly by the system.

The heart of the problem is that the state provides counties health, mental health and social services funding by population, but there is often a "minimum amount" provided to smaller counties. Counties like Sierra, Alpine and Trinity might well be receiving too much funding per capita, resulting in too much service. There is a slow backlash building against government intrusion in the name of "helping" which began with conservative Christian families who home school, and is building.

Counter that with a HHS culture from the state level which encourages, even mandates, county directors to provide all the services they possibly can.

While there is a growing feeling that something should be done to reign in HHS, it is not clear exactly how that would be done, or what the consequences might be.

The Lay of the Land

Sierra County isn’t an easy place to belong; to be "from here" you are born in the county, or at least have dedicated a third or more of your life and have had children here. Dr. Roberts isn’t from here, and the next Director is not likely to be, either. The current Director isn’t even from here in the sense that some summer residents and relative newcomers are from here. She’s not even from here in the sense that she necessarily lives here.

Not being from here, we can imagine that any Director, while being in charge of the entire shooting match, is also at the mercy of staff to some degree. They live here, and many are from here. Some were here before the Director came and will be here when he or she leaves. These employees, and their families, constitute a significant proportion of the people the Director must consider. If she cuts a position, someone’s family suffers. This might explain her strong loyalty to staff.

At the same time, higher level staff are likely not of the county. They likely share more in education and experience with the Director. Like the Director, they have a considerable investment in their careers. Many of these players are not here for the long haul. To get ahead in their profession, they have to move around. Many don’t care for local provisions. They like to eat in fine restaurants, send their kids to the most tech savvy schools, spend their free time enjoying "culture". There is a strong local preference for people who receive the big county bucks to live in county. This might, we can guess, create some difficult emotional terrain for her to navigate.

To make matters worse for the present Director, the department is down a key player: there is currently no assistant director. Being without one leaves the department without back up and a "right hand person".

The Director also has to deal with other significant agents and forces.

The Job

To people in health, mental health, and social services delivery, the idea of helping people is not theoretical. They see the success stories: people who couldn’t function without meds and frequent guidance who are living nearly normal lives. People who couldn’t stay out of jail if it weren’t for services. Women who live without fear, children who are safe from lead, hunger, and second hand smoke. Hundreds of children in the county who didn’t get rubella, didn’t get diphtheria. Those stories, and there are many right in our community, are what motivate even the most jaded social service provider.

The Director’s primary job isn’t to deliver services, or even directly oversee the delivery of services, but the position still deserves credit for the benefits the community receives. The Director isn’t supposed to know what each social worker is doing, she or he is supposed to set policy and procedures to ensure:

  1. The safety of the organization, largely meaning risk management and liability reduction. This translates to compliance with law and accepted practice; evidence of compliance is the one thing which can protect an agency from lawsuit.
  2. Funding. Funding is food; no funding and the body of the agency dies. Staff go without wages, clients without services.
  3. Her job and career. The agency is important, but frankly, if Dr. Roberts believes she is being put into a position to endanger her career, she has no option but to push away from the agency.

The proficient delivery of services to clients is a natural outcome of pursuing those goals, as is staff safety.

To be clear, most of the professional influences in her life will encourage her to more funding and more services. The Director position is responsible to a number of different parties. If a social worker or driver screws up, it will be up to the Director to apologize and describe what measures are taken to make certain the event doesn’t happen again. She or he will be expected to do this even if the employee was not completely at fault.

The Director will also be required to follow protocol to investigate, provide a finding, and describe corrective action. The authority she or he would report to depends on the nature of the event, the participants, and the funding stream or other legitimizing authority, and probably to the Board, the public and the press.

In most other counties, there would be from three to ten people directly beneath the Director, each with a specific expertise in their programs, each answerable for a certain budget and for oversight of service delivery. Dr. Roberts is responsible for all those herself. Normally, each of those positions would travel at least once or twice a month to learn of new regulations and funding opportunities. Miss them, and you miss valuable information and networking.

Chances are good, too, that the Director’s next job will be found at one of those meetings, or at least that the networking she does will be vital to getting the next position.

The State

It is not completely clear if following Board of Supervisors directives could relieve Dr. Roberts of all the requirements of her position. Directors are, in some instances, liable for decisions which result in improper or inadequate services. In extreme circumstances there might be criminal charges.

For a professional, the resume has a value all its own. Even without charges or state action, the Director has to protect his or her reputation or accept retirement, and the current Director is too young to retire.

The state goes after funding first. If, even for strong political reasons, the agency fails significantly, an audit might be called, and funding might be withdrawn or the state might threaten to take over services (very unlikely). If there is evidence of gross negligence, the state might require the county to follow a corrective action plan or look for fines. At the very least, the Director would be faced with personal interactions with state personnel, who would, on a personal level, wonder what is wrong with the county. The Director is, on many levels, compelled to consider the state first.

On the other hand, there is a growing feeling among the counties that the state is sick, toothless and vulnerable to challenge.

The Board

Sierra County isn’t like many other places. When something happens to a family, the supervisor hears about it. They hear about it in the grocery store, in the local cantina, in the post office, and all hours of the day and night.

Further, there reside in Sierra County people who hold to old values like thrift and self-reliance.

Dr. Roberts at a recent Board meeting; beyond her are County Council Jim Curtis and County Clerk Heather Foster
The community has experienced a great deal of "institutionalization" because the per capita number of cops, social service and mental health providers is high. Here "institutionalized" does not mean only "sent to an institution" but also to means people who have a learned dependence on, and are indoctrinated to work well within, structures of social service provision. People are resentful, but dis-empowered, and are unlikely to complain, but very likely to stir subsurface resentment. Having the state in your family or your head is often not a pleasant thing. People who have that experience complain to their supervisors, many times.

All of this comes together to make life difficult for Dr. Roberts or anyone in that position. The position bears a responsibility to the clients, the state, and the Director’s career, which rival the power of the Board to control spending and regulate staff. The Board isn’t supposed to micromanage, but they have the power to make the Director miserable.

There are funds which she can’t access without Board approval. There are funds she or he might use against the wishes of the Board, but if the Director does that, she or he is not likely to remain in the position. A department head at war with the Board will lose eventually.

The Public

It is not hard to find Carol Roberts supporters among staff and clients. Many people who work with Carol often like her very much, and find her to be anxious to find ways to cooperate. She is not forceful as some past directors have been, but can dig her heels in when pushed.

Many members of the public might tend to assign the agency whatever thoughts and emotions they hold toward the particular services and providers they do have experience with.

Even in Communist China, public opinion matters, and here in Sierra County, it is king. People don’t forget here, the stories circulate forever. Not everyone in the county has had a good experience with HHS.

The Press

The press is an idiot with a particularly large voice and an extremely selective memory. All media are extraordinarily fickle, and can think only of the moment, as though they were all captained by 13 year olds. In truth, they are being run for 13 year olds, in the sense that most Americans read and comprehend at the 7th grade level. Most media outlets don’t actually intend to educate or inform their consumers, but to pander to them. They want consumers emotionally "engaged" and too much information can inhibit the enjoyment of news.

The press in the Director’s world ranges from critical to oblivious. The Messenger has been recently critical about one staff member and the department she works for, and is generally dubious of federal money. The Booster will report on what the readers want to read about, and is generally dubious of federal money. The Prospect… God knows what the Prospect thinks.

Still, it is the press which is providing the motor force for a movement on the Board and on the street to curb government help, and to curtail government waste. It is unlikely that the Messenger will cease its investigations until something is done about a single social worker, and the Prospect will certainly continue to seek a more realistic balance in CWS and mental health. Ours is a small county, there is no reason we should not set the threshold of government help.

What would you do?

We might speculate on what Dr. Roberts will chose to do, but we can’t actually second guess her. She has information we don’t, and advisors we can’t guess at. She might have avenues open which we can’t imagine. She might have an offer of a job elsewhere.

Still, in the normal course of things, we might expect any Director to do what a successful general or corporate head would do.

The Director might defuse public anger and resentment by providing an opportunity for public input. There are a couple of areas where local people have been "helped" out of their families and jobs, but the major one is Child Welfare Services. The Director could not discuss any single case, or even any social worker or staff member, unless charges or lawsuit have been announced, and even then, she couldn’t say much.

But she could enlist the public, make them partners in determining where the line on child welfare services and mental health services should lie, within the discretion allowed by law. The agency can hardly lose doing this, since many of the people who will come forward will be teachers, social workers, public health providers and others who can give first hand tales of woe. Very often school officials are frustrated at what should be a separation between the education code and Welfare and Institutions code, which prevents social workers from cleaning up kids and modifying family behavior as much as school officials would like. It would be fairly easy to get "professionals" to come forward and give testimony in favor of all the government intrusion we can afford. It’s for our own freakin’ good, what don’t we get about that?

In addition, those who have had unhappy experiences with the agencies won’t be likely to come forward. Doing so will require them to admit their personal failures and expose their family to stigma.

Except for the press, and a few other stalwarts, there is little to discourage public discourse which forum the agency would automatically manage.

Further, in such a forum a Director might actually discover that people and families are being over served. This is valuable information she or he can use to set protocols for mental health and particularly for Child Welfare Services which will restore some personal liberty and decrease the institutionalization of county residents.

Not having a public opportunity would leave the danger that the press or other public group might call for one, which the agency would then not control.

The Director might get tough with the Board. It works like this: "I have a responsibility to the needy in the community, and to the state, which over-ride the momentary political goals of this Board. Either let me run my department as I see fit, or I’m leaving you with no director and no assistant director." This is gutsy and dangerous, and not a great idea since some on the Board aren’t that connected with HHS, and because governments everywhere are downsizing, meaning more professionals than jobs.

Researcher Ashley Cabrera and Dr. Roberts at Teen Center meeting
If you were Director you might simply acquiesce and drop the Teen Center, drop the two staff positions from the agency, do nothing else and look for a job somewhere else. This might work, as media and public attention wane and wander off to be concerned about something else, but it leaves a "pot on the stove" so to speak. Further, the Teen Center has strong support among teens, and Dr. Roberts seems dedicated to the idea. A good solution would be found in locating the Teen Center somewhere else.

It is popular with corporations and public agencies to do a "round table." A round table is different from a public meeting in that only key players are invited. These players would include county and city leaders, local service professionals like doctors and teachers, and the press. The public is represented by local officials and the press, who are more easily educated and convinced than the general rabble. Properly run, a round table is a medium for changing opinion in the 15% of the population that really matters. Perhaps if you were the Director, you would consider this option.

Finally, any good multiple choice has "all of the above." While it is difficult to do without an assistant director, the round table and other forms of image management including a public forum, if there is the will for one in the community, are good ideas. A willingness to drop the teen center in the face of public insistence is likely to be met with cries for a teen center. Some decisions are simply a matter of the least damaging option.

Dr. Roberts has experience and resources beyond our speculation, and might have completely different strategies for dealing with the current resistance from the public, Board and press. It will be interesting to see how this tension in our community resolves itself.

Still, those asking for a change should also ask themselves: what would they do if they were Director of Health and Human Services?


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