This summer marks five years since the publication of the Sláintecare health reform report. David Lynch takes stock of progress in the Government’s 10-year plan to create ‘universal healthcare’
On the final day of May 2017, the Oireachtas committee on the future of healthcare published Sláintecare with cross-party support. Set out as a decade-long programme to radically transform the health system, its recent fifth birthday passed with hopes of progress, but also concerns over implementation, cost, and recruitment.
According to the Sláintecare Implementation Strategy and Action Plan 2021- 2023, the ultimate vision of the plan “is to achieve a universal single-tier health and social care system, where everyone has equitable access to services based on need and not ability to pay”.
So halfway into the 10 years, how are we doing?
Minister for Health Stephen Donnelly struck an optimistic note upon the recent publication of the Sláintecare Action Plan 2022. He said 2022 had witnessed “considerable progress in the areas of waiting lists [and] the national elective ambulatory strategy and regional health areas (RHAs)”.
“The Government has approved the next steps for RHAs implementation…. This is key to delivering on the Sláintecare vision of an integrated health and social care service, improving the quality of our community health services.”
However, questions about progress so far and prospects for the next five years have been raised by some.
Health Economist at University College Cork, Dr Brian Turner (PhD), told the IMO AGM in May that it was time for a “review”.
“Yes, I suggested at the AGM that it might be time for a review of the plan at this stage,” he told the Medical Independent (MI).
Deploying business parlance, he said that such an undertaking “could be seen as a mid-term strategy review”.
The first reason the academic believes it is time for a review is because Ireland’s health service in 2022 is not the same as 2017. “A lot has happened in the health system” since the report was launched, he said, “not least of which is the pandemic.”
Dr Turner added that the experience of Covid-19 had highlighted positive aspects of the system, including the capacity to “coordinate a very effective nationwide vaccination campaign”. But the impact of the virus has also focused attention on negative aspects of the system, including “capacity issues in certain areas and particularly the vulnerability of our ICU capacity”.
“It [the pandemic] has also led to a renewed focus on public health, which might need to be reflected in the strategy.”
The original report included public health aspects, “but at that stage  I don’t think anyone could have envisaged
the type of public health initiatives that we’ve seen in the last two years and may well see continuing for some time.”
Another impetus for a review is cost. “At this stage, the cost estimates for numerous elements of the plan, not least the type of capacity expansion that was envisaged by Sláintecare, will need to be updated,” said Dr Turner.
“The cost of the physical capacity such as hospitals, primary care centres, etc, is likely to be considerably higher, given construction inflation since the plan was published.”
He referenced ESRI research “suggesting that the additional bed capacity called for by Sláintecare [2,600 hospital beds] won’t be enough to cater for forecast demand, so this may need to be revisited”.
But beyond bricks and mortar, it is the industrial relations landscape that will also prove challenging.
Who is in charge?
Last September Ms Laura Magahy, the Executive Director of the Sláintecare Programme Office, and Prof Tom Keane, the Chairperson of the Sláintecare implementation advisory council (SIAC), resigned citing concerns over implementation.
The high-profile resignations sparked significant changes in the reform governance of the plan.
In late 2021 a Sláintecare Programme Board was established, which was co-chaired by the Secretary General of the Department of Health and the HSE CEO.
According to the Department “the Sláintecare Programme Board provides senior official interagency oversight of the Sláintecare reform programme and provides focus for the delivery of a universal healthcare system through implementation of the Sláintecare reform programmes”.
This board will see further changes in personnel with Mr Paul Reid stepping down as HSE CEO this December.
The new Sláintecare Programme Management Office (SPMO) has also been established “reporting to an Assistant Secretary in the Department of Health”. It provides “support and project management oversight to the delivery of the Sláintecare reform projects across the Department”, a Department spokesperson said. The SPMO comprises a team of eight including an “externally sourced” manager. However, the spokesperson added that “all divisions within the Department of Health” are responsible for the implementation of Sláintecare.
Assessing the performance to date of this new governance arrangement, Dr Sara Burke from the Centre for Health Policy and Management, Trinity College Dublin, believes it is “probably too early to tell… my sense is that they only got out of the traps this year on it”.
However, she does envision possible problems with the new governance arrangements.
“I expressed my concerns at the time of the resignations [of Ms Laura Magahy and Prof Tom Keane], with the appointment of [Mr] Robert Watt [the Secretary General of the Department of Health] and [Mr] Paul Reid [to lead the Sláintecare Programme Board]. The problem with them being responsible for reform is that they’re [also] responsible for the day-to-day running of the health system and when you’re doing that, the urgent always trumps the important,” she told Medical Independent.
“So they don’t have the time or the bandwidth to do the long-term strategic reform, no matter what the intent. That was the purpose of the dedicated office [led by Ms Magahy] there before. So I’ve concerns with the new structures in place.”
However, she added: “I do understand that you need to get the structures on board and the HSE and the Department of Health needs to change to implement this whole system of reform… so I think it’s too early to tell.”
She believes that the Sláintecare progress report for the second half of last year showed “a significant slowing down on progress”.
“That for me wasn’t coincidental. l think that coincided with the resignations of Laura Magahy and Tom Keane. My concern is that you lose the momentum and drive without the reform office.”
“On the workforce side of things, it looks like there may be further issues to be addressed in relation to recruitment and retention, including the very negative reaction of consultants to the draft Sláintecare [consultant] contract, the recent NCHD vote for industrial action,
the strike action already taken by medical scientists and the ongoing unease among nurses about pay and conditions,” said Dr Turner.
He noted that the cost of healthcare workforce requirements “will have risen as well and will continue to do so… due to the likely renegotiation of the public sector pay deal in light of the cost of living crisis”.
Against this turbulent backdrop, talks on a new consultant contract have restarted between the Department of Health, HSE, IMO, and IHCA. There is a general consensus that a successful completion of the contract negotiations is a prerequisite to the implementation of much of the vision outlined in the 10-year plan. This is something that is recognised implicitly in the Government’s Sláintecare Action Plan 2022.
Dr Niamh Humphries (PhD), Senior Lecturer at the RCSI Graduate School of Healthcare Management and part of the Hospital Doctor Retention and Motivation (HDRM) project, told MI “our research on the HDRM project has shown just how busy hospital doctors are on a day-to-day basis”.
“If hospital doctors are struggling to find the time and space and resources to get their job done today, how are they going to find time to also improve the system and to implement Sláintecare reforms?”
Dr Humphries said that consultant numbers are vital to any success for the programme. “Staffing is key to Sláintecare,” she commented.
In a statement released in early June to mark Sláintecare’s fifth birthday, the IHCA president Prof Alan Irvine struck a far from celebratory note.
“Today marks five years since the Government launched Sláintecare, yet as we reach the halfway point of this a 10-year plan, we are faced with a health service [where] staff and patients… are suffering more than ever,” warned Prof Irvine.
“The reality is that Sláintecare waiting list targets are not achievable because public hospitals have a severe shortage of consultants, theatres, acute beds, diagnostics, and other facilities…. This plan needs to be resourced properly, yet five years on and Sláintecare is still failing on these important factors and is not delivering on capacity and staffing commitments.”
For Prof Irvine, Sláintecare will fail unless the “Government and health service management seriously address the root causes of these continuing deficits”.
For his part the Minister for Health is on record that he wants a new consultant contract agreed this year. But, the general timelines around implementation of wider aspects of the Sláintecare programme have often proved fluid.
Dr Turner noted that “the timing of some of the measures in Sláintecare have changed”.
“For example, the removal of public hospital charges was scheduled for year one of the plan, but this still hasn’t happened, while the drug payments scheme threshold and the prescription charges started to be reduced before they were scheduled to do so. This would need to be reflected in any updated plan, and it might be no harm to review whether other priorities have also changed.”
Dr Sara Burke (PhD) is Research Assistant Professor of Health Policy in the Centre for Health Policy and Management in the School of Medicine, Trinity College Dublin (TCD). She believes the current consultant contract talks will be an “indicator of how serious the political system is, in terms of really providing better access to the public system”.
“The public-only [consultant] contract and the extension of entitlements to care are two of the things they’ve [the Government] been slowest on, but they’re really important elements to delivering universal healthcare,” she told MI.
In 2017 Dr Burke worked with the Oireachtas committee on the future of healthcare on the production of the Sláintecare report. She regards the slowness of contract talks as “symptomatic” of wider challenges around implementation since last year’s resignation of Ms Laura Magahy, the former Executive Director of the Sláintecare Programme Office, and Prof Tom Keane, the former Chair of the Sláintecare implementation advisory council (SIAC).
“Who is actually responsible for Sláintecare’s implementation?” she asked. “I never heard clarity on that matter and I think that is very problematic… because we know if there is someone at the top responsible for delivery, it is more likely to happen… I think that is a real issue. It’s a governance issue, a particular failure of reform governance.”
Looking towards the coming five years, Dr Burke thinks the next election will have a significant impact on the future progress of the plan.
“When it was published [in 2017] I said it would take two governments to test whether it will be implemented or not. I actually now think it will take three governments… the next government will make or break it and I think the makeup of the government is crucial to whether it just carries on in a piecemeal slow way… rather than the more radical project that was originally envisaged.”
She stated that “health policy is like an aircraft carrier, it’s very hard to change the direction of it”, and that the last five years had seen some “positive” shift in the direction of health policy. A decade ago “we were in the middle of austerity [and] there was a lot more [of a] privatisation agenda in health…. The system is [now] moving towards a universal health system… albeit in a slow way.”
Noting the Government’s plan to abolish inpatient charges for children in public hospitals, Dr Burke said it was a “drop in the ocean, but stuff like that is important” in the creation of a universal healthcare system.
The negotiations that could make or break Sláintecare
The recently restarted talks on a new public-only contract are seen as vital to dealing with the consultant “recruitment and retention” crisis.
However, the fundamental importance of the talks to the success of Sláintecare is also becoming clearer.
In the Dáil in March, the Minister for Health Stephen Donnelly restated that the removal of private practice from public hospitals was a “core principle” of Sláintecare.
But the recently published Sláintecare Action Plan 2022 implicitly stated that this “core principle” was reliant on a successful conclusion to the current contract negotiations.
The plan stated that in the fourth quarter of this year, the Government would “progress plans to remove private care from public hospitals”; however, this is “subject to agreement with representative bodies on the introduction of the Sláintecare contract”.
Talks on a new consultant contract resumed last month under the new independent Chair, Mr Tom Mallon BL. The talks had been stalled for the past six months after the previous Chair stepped down to take up a new post.
However, it is the proposed ban on private work in any future public-only Sláintecare consultant contract that may yet prove to be one of the most difficult issues to reach agreement on.
At the end of 2019, the IHCA said the plan to remove private practice from public hospitals would lead to “an annual funding hole of €650 million” and “wreak havoc on patients”.
In a wide ranging discussion about aspects of a future contract at the IMO AGM in May, the “public-only provision and proposal to restrict out of contract time”, was raised by the Organisation‘s consultant committee Chair, Prof Matthew Sadlier.
Prof Sadlier, Consultant Psychiatrist and Clinical Director, North Dublin, said: “I suppose this is, maybe, a little more [of a] controversial topic.”
“This is [the] concept of when you have done your 39 hours in the public service, when you’ve done your contractual hours the consultant contract should not prevent you from working medically for a private provider outside of your 39 hours.”
“Now, at the weekends I can go do landscape gardening if I want. I can go and work in any other job that I want, but I’m not allowed to go work in private medicine? So, it is a restriction on trade… and this is an issue with the contract.”
Speaking to MI at the AGM, Minister Donnelly said: “We do need it [a new contract] agreed this year, it has to be agreed this year.”