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During his brief tenure as head of the PCCC, Mr Browne may be best remembered as the man who was asked to explain the deficiencies in the system which led to the Leas Cross controversy. It was also expected that he would drive forward reform in primary care, but there have been little signs so far of real progress being made in this area.

Reform inertia

This was not necessarily Mr Browne’s fault and it may be argued that the inertia in reforming general practice goes deeper than one man or one group of men. But there is a deeper question of whether and how well our system of public management would have encouraged and rewarded significant, calculated risks, had he opted to take them.

Mr Bowne’s principal error, or at least one of his major errors– may have been his failure to find a strategic way of brushing aside the structural barriers that still stand in the way of health reform.

Among these is a shadowy entity within the HSE, called the National Employment Monitoring Office, which has the final say over whether front-line staff, including those on sick leave or maternity leave, can be replaced. Known as NEMO, it’s nothing like the colourful clown fish in the eponymous computer-animated movie, but is more like the menacing white pointer shark, Bruce.

Finding NEMO

NEMO is now wreaking havoc in health services to the extent that unions are threatening not to co-operate with the roll out of the primary care teams, the mainstay of a reformed health service, because of the difficulties in replacing front-line staff who are absent, even temporarily.

In theory, the reforms are about devolving power and responsibility to the local level to things get done. In practice, managers who need more front-line staff to deliver all these new services are being given no say, nor control over the composition of their headcount.

The most pressing need may be for a public health nurse, but if a vacancy occurs in the back office and there are enough back office staff around, the manager is still likely to get approval only for a clerk.

Massive overheads

This bureaucratic madness involves a massive overhead in time and effort, up to and including HSE national directorates. Inevitably, it brings senior managers into areas where they should not be, and makes front-line services difficult to maintain, much less expand.

Even that one example is symptomatic of a deeper malaise within the reform programme. Some of the problems are due to the organisation and funding of front-line services, some to the carry-over of outdated practices and procedures and some to the very legislation that set up the HSE.

Hospitals have always been the most high-profile and most cost-intensive part of the health sector, but also the most difficult area in which to constrain the growth in spending. As a result, primary and community services are still under-provided.

In addition, in order to make the transition to the HSE acceptable to the unions, provision was made that anyone who was permanent and pensionable under the old system would retain their terms and conditions in the new regime.

Sharp criticism

While that move has been sharply criticised by many, it was important in terms of ensuring that capabilities built up over many years, and vital in providing complex, personalised health services, were not lost in the change over. The downside is that outdated personnel practices and procedures means managers don’t have the freedom to use money and people to respond effectively to new demands.

The problem is compounded by the legislation that abolished many of the old health agencies, which appears to be principally administrative and technical in its focus.

Ministers often see reform as a clean way of preventing the recurrence of problems caused by fragmentation. The failed computer system PPARs is a case in point.

The more significant issue is that if objectives for the health services are not made explicit and enshrined in legislation, it is much more difficult to ensure that resources go where they are needed, and to achieve coherence between health policy and managerial and professional performance in the delivery of services.

Increasingly, health service managers have had to fulfil a wide variety of roles: producer and administrator, integrator and entrepreneur, media performer and stakeholder manager. The archetypal public servant in Ireland fulfils the producer/administrator role admirably. But our system of pubic management has yet to appreciate the value of those other roles, and to untie the hands of its public servants to fulfil them.