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It is just over three months since the Oireachtas Committee on the Future of Healthcare published its report on the final day of May.
The much-anticipated 10-year plan for health, called Sláintecare, was signed by representatives of all political parties on the Committee (apart from Solidarity TD Mick Barry) and was launched amid much goodwill and optimism.
The report outlines a vision for the Irish health service that, if implemented, would see a major shift from secondary to primary care, a restructuring of the HSE, the end of private services in public hospitals, free GP care for all, maximum waiting lists guaranteed by legislation, and hospital management held accountable by law.
The plan calls for ongoing investment in the region of €2.8 billion over a 10-year period to build-up the necessary capacity and expand entitlements. Added to this, a transitional fund of €3 billion to support investment across the health system in areas such as infrastructure, eHealth and an expansion of training capacity is recommended. The total implementation bill is €5.8 billion over the next decade.
However, there is already concern that the Government has been slow to implement aspects of the report’s tight timeline.
The report made clear that a Sláintecare implementation office should be set up under the auspices of An Taoiseach by July 2017, “with the remit to oversee and enable the implementation of this plan”.
That this deadline was missed was publicly noted by the Health Reform Alliance, which expressed “disappointment” that the date passed “without any tangible action”.
However, as reported in our separate news story (see page 6), there are currently inter-departmental discussions taking place regarding the recruitment of a ‘lead executive’ and other personnel for a dedicated ‘Sláintecare Programme Office’.
Nonetheless, former members of the Committee on the Future of Healthcare admit to the Medical Independent (MI) that some “momentum” may have been lost following the report’s publication because of the election process for the new Taoiseach and the summer recess. But they agree that the coming weeks are crucial.
Former Chairperson of the Committee, Deputy Róisín Shortall (Social Democrats), told this newspaper that the report was “affected by the change in Government personnel”.
“From that point of view, we were a bit unlucky with the timing because we had intended having a high-level meeting with the Taoiseach at that point, who was Enda Kenny, and then lining things up,” she said.
“But then there was the change [in Taoiseach] and uncertainty about the Minister and all that after we launched. There was a bit of slippage in time because of that, which was unfortunate, but nothing could be done about it. Then there was the summer break.”
Another leading member of the Committee, Co Clare GP Dr Michael Harty (Independent), said he is “concerned that momentum has dropped off”.
“But I wouldn’t give up hope entirely,” Dr Harty told MI.
“The summer recess came within five or six weeks of the report being published. It was published prior to the election of the Taoiseach. So there was a lot going on over those five or six weeks to distract the Government.
Dr Michael Harty TD
“But certainly when it [the Government and Dáil] returns, I would expect that if there isn’t a very strong commitment to setting up the implementation body, this report could end up like many other reports — just gathering dust.”
The importance of the implementation office cannot be underestimated, said Dr Harty.
“Yes, I think the first step for the Government if it’s going to be serious about this is to set up an implementation body to oversee the report and its findings,” he maintained.
“That is the first step. Essentially, if that isn’t set up, nothing can happen.”
His views are shared within the medical community. The creation of an implementation office for Sláintecare is crucial for the success of the 10-year plan for healthcare, RCPI CEO Mr Leo Kearns recently told MI.
“I spoke about an implementation vehicle. I think from our perspective [RCPI], generally speaking there is a reasonable consensus around the various things that need to happen,” he told MI at the Private Hospitals Association conference in Dublin in June.
“But we absolutely have to have a vehicle that is going to make that change happen right across the system. So if that doesn’t get established, it is hard to see it going anywhere… I think in the Sláintecare report, as well as in our own report [Towards 2026], that is a key thing.”
Deputy Shortall revealed to this newspaper that “there were a couple of names doing the rounds” when the Committee discussed who could possibly be the Lead Executive in a new Sláintecare office.
“The Committee was going to propose our view and then put it to Taoiseach Enda Kenny at the time, but that opportunity was lost then [because of the election for Taoiseach],” says Deputy Shortall. The Committee in the end did not recommend any particular individual to be lead executive.
The Department of Health also confirmed to this newspaper that another review sparked by the publication of Sláintecare has yet to begin.
“The report recommended that an independent impact analysis of the separation of private practice from the public system would be undertaken. This analysis has not commenced and will be considered as part of the development of the overall response to the report,” said the Department spokesperson.
“Minister Harris sees huge benefit in a cross-party approach to health, has been a constant advocate of it and is excited about taking these next important steps.”
The spokesperson insisted that Minister Harris supports the Sláintecare report.
“Minister for Health Simon Harris has been very clear that making tangible and sustainable improvements in our health service is a key priority for this Government,” the Department spokesperson told MI.
Minister for Health Simon Harris
“He fully supported the establishment of the All-Party Committee on the Future of Healthcare and has consistently supported its work, which he firmly believes can provide a once-in-a-generation opportunity to transform our health services. He has welcomed the level of cross-party support for the Committee’s report.”
In late June, Minister Harris told the Dáil that the “Taoiseach tasked me with preparing a detailed response to the report, including proposed measures and timelines, to bring to the Government”.
MI understands this “detailed response” is still being developed and the Department did not give a time frame for when it was expected to be delivered.
Dr Harty believes a clear statement of support for Sláintecare from the Government and the Taoiseach is vital.
“Well, we have had no response from the Government to date,” Dr Harty told MI.
“There was a debate in the Dáil, which hasn’t been completed. It is to finish sometime in the middle or the end of September. Not everyone had an opportunity to speak in the two hours that were allotted to it.
“But officially, there has been no response from the Government in relation to it [Sláintecare].
“The Minister [for Health Simon Harris] I understand has been asked by the Taoiseach to bring a report to Cabinet,” said Dr Harty.
“But I think also the Taoiseach needs to make a statement that he is going to commit to implementing health reform, as laid out in the Sláintecare report.
“He needs to give a strong political commitment to it because without strong political commitment, this report is probably not going to go anywhere.”
In Leaders’ questions in the Dáil on 28 June, Taoiseach Leo Varadkar was non-committal in his response to the report.
The Taoiseach noted that Government policy on health is “as outlined in the Programme for Government” and stated that he had tasked Minister Harris to “develop a reasoned response to it [Sláintecare] on behalf of the Government and decide whether to accept it in full or in part”.
Notably, the Taoiseach also cautioned that “several issues need to be teased-out, not least that the initial view of the Department of Public Expenditure and Reform is that the costings in the report are not accurate”.
Deputy Róisin Shortall
However, Deputy Shortall told MI that she was due to meet the Taoiseach as MI went to press, with members of the Trinity College Dublin health economist team. This team provided much of the costing for the Sláintecare report.
“That is an important session I think,” Deputy Shortall told MI prior to the meeting.
“We haven’t had an opportunity to brief the Taoiseach because of him coming in so late in our process [after his election]. He is very keen to get the background information from the research team.”
There has been scepticism from medical unions, health analysts and other parties about the accuracy of the costings of the report, with the consensus being that the projected costs of implementing the major changes in the report are not realistic or robust enough.
The Society of Actuaries Healthcare Committee is understood to be in the process of drafting a letter to Minister Harris in response to the report, which will likely raise concern about the validity of the costings, especially in relation to the recommended removal of private healthcare services from public hospitals.
On the costing of the report’s recommendations, Dr Harty said, “we took the costing as best we could from various sources and we came up with the best ball-park figure we could for costing”.
“It is a difficult thing to cost exactly; it depends on how the implementation was to be phased, how rapidly it is to be implemented. So there is a lot of leeway in terms of costing.”
Dr Harty added that legislation to underpin accountability and responsibility in the HSE is also needed.
“Most of those measures don’t require huge investment, but they do indicate that the Government is committed to progressing the recommendations in the Sláintecare report. It then depends on how rapidly you are going to roll it out.”
Focusing minds: Building to the Budget
Interest in the Sláintecare report is going “to ramp-up again in the autumn, as soon as the Dáil is back,” Deputy Shortall predicted when talking to MI.
The former Chair of the Future of Healthcare Committee said that the Dáil debate on the report would be resuming, “which is something I hope will be happening the week we are back, which is the week of the 20th [September]”.
But it is not only in Leinster House where interest in Sláintecare is to be found.
“Pressure for the implementation of Sláintecare is growing outside of the Dáil. I think basically, all the health advocacy groups are very supportive; some of them had conferences on it before the summer break,” said Deputy Shortall.
She also points to upcoming seminars by Trinity College Dublin, the Health Reform Alliance, RCPI and the College of Anaesthetists that will look at aspects of Sláintecare.
But the former Minister of State for Primary Care also believes the pre-Budget 2018 season and the wider debates around fiscal policy will see a concentration of minds around Sláintecare.
“There is a lot of activity around it. And obviously, in the lead-in to the Budget, there is going to be a lot of pressure on to commit to implementing Sláintecare. My understanding is that the Irish Congress of Trade Unions (ICTU) will be making that one of its [Budget] demands,” Deputy Shortall told MI.
“So obviously, there is an issue about the fiscal space this year. It is not settled what the priorities are going to be for the Government. They are talking about trying to do tax cuts, and also capital investment. Certainly, I would argue strongly from my own perspective that the country is not in a position to have tax cuts at the moment, because there is such a degree of unmet need — notably in the health sector area, but also housing, childcare, indeed across a whole range of services.”
The Social Democrat TD notes that there will “be political decisions around that” but she thinks the majority of parties in the Dáil are focused more on funding public services than tax cuts, with the possible exception of Fine Gael.
“Fine Gael seems to be quite wedded to tax cuts. That is the bigger-picture argument that is going on.”
But she insists that in terms of health, “there is no other game in town”.
“This is a well-thought-out report with a very strong evidence base within it. Our biggest problem is the narrowness of the fiscal space at the moment,” said Deputy Shortall.
“Yes, it does require a significant commitment to fund the reform programme. One of the criticisms is that we are already spending a lot of money on health and there is no doubt about that.
“But we have been talking for 20 years about reorienting the health service and making primary care the centrepiece of the health service.
“Given the fact that our health service is operating on a knife-edge at the moment, it is not possible to take funding from the hospital sector and put it into primary care, because of the long waiting lists.
“So the Committee very much came to the conclusion that you need to front-load funding to create the capacity in primary care so that then you can switch activity and then you can get the savings. So you have to spend to save.”
“I think, critically, the first step will have to be a GP contract which would encourage GPs to enter the system and young graduates who have left the country to come home,” Dr Harty maintained.
“But unless there is a strong, robust primary care structure on which this report is based and the reforms are based, then it can’t progress.”
In terms of the new GP contract, the NAGP is holding an emergency meeting of members on 23 September “to decide the next steps our organisation may take to support the viability of general practice in a functional and efficient health service”.
That is according to Mr Chris Goodey, NAGP Chief Executive, who told MI that the implementation of Sláintecare must be linked to an agreement around a new GP contract.
“Despite the publication of the Sláintecare report in May, no discernible progress has been made to deliver a decisive shift to GP-led primary care,” Mr Goodey told MI.
Mr Chris Goodey, NAGP CEO
“At the time of its publication, the NAGP cautioned that the report could only be implemented by restoring viability to general practice through reinvestment and the successful negotiation of a new GP contract.
“Neither the implementation of the Sláintecare report nor the negotiation of a new GP contract are happening at the required pace to deliver the healthcare system patients deserve.”
Mr Goodey said NAGP members are “concerned about the slow pace of contract negotiations”.
“Ireland continues to be among the highest spenders on healthcare, whilst being among the lowest performers. Implementation of the Sláintecare report and the negotiation of a new GP contract must take place within a more reasonable time frame to address the urgent need for a functioning health system.”
By the time of going to press, the IMO had not provided comment on Sláintecare progress.
Despite the arguably slow pace over the last three months, both Deputy Shortall and Dr Harty remain strongly committed to Sláintecare
“Yes, I mean, what is happening in the health service at the moment, tinkering around the edges, making changes in a very sporadic fashion, is not going to reform the health service, so this is the only plan that is available,” said Dr Harty.
“It is the best plan that we could come up with, having deliberated for 11 months. It gives a direction in which the health service should go. It is not the complete answer to reform, but it is sending reform in the right direction.
“If in the winter, as we can anticipate the trolley count goes up and the chaos in our emergency departments continues, with waiting lists elongated even further, you can point to the report and say ‘at least here is a plan’.
“A plan that if you start to implement it over a 10-year period, then you will have a functioning health service at the end of that time.”
Deputy Shortall stressed that Sláintecare remains the “only game in town”.
“Overall, the report has been very well received. All the patient groups and most of the advocacy groups are very much in favour of it. I think most of the research bodies favour it as well,” she commented.
“The main point is that there is no ‘plan B’. Our health service has been dogged by political infighting; the whole intention of the Committee was to end that situation. We have a political consensus and that is a very strong starting point.
“I think any Minister for Health or any Government would be foolish to ignore that.”