IN MAY 2017, the Committee on the Future of Healthcare published its final report.

The committee had been founded following the 2016 general election in order to get cross-party consensus on the long-term vision for healthcare and health policy in Ireland, and to make recommendations to the Dáil.

The Sláintecare Report, as it was called, presented a detailed vision for the future of healthcare in Ireland. Among its many key recommendations were the elimination of Ireland’s two-tier health system, the removal of inpatient charges, an expansion of primary care into the community, and the introduction of universal palliative care.

“This report represents a new vision for the future of healthcare in Ireland. The Committee considers it imperative that its recommendations are implemented without delay,” Social Democrat TD Róisín Shortall, who chaired the committee, said on its launch.

Almost five years later, however, progress on implementing Sláintecare has been slow. While the current government has had to deal with the Covid-19 pandemic and a crippling cyber attack on the HSE in the meantime, it has also been criticised for not implementing reform in the spirit of the original Sláintecare report.

Key figures involved in its implementation have resigned from their positions, and the government has been accused of “cherry picking” parts of the plan and ignoring others.

What is Sláintecare?

Put simply, Sláintecare is the name for the initiative to reform Ireland’s healthcare to move away from a two-tier system and towards a system based on medical need.

“Our task has been to consider how best to ensure that, in future, everyone has access to an affordable, universal, single-tier healthcare system, in which patients are treated promptly on the basis of need, rather than ability to pay,” said Róisín Shortall in 2017.

At its core, Sláintecare aims to tackle the main problems faced by healthcare in Ireland: patient care, waiting lists, high costs, overreliance on hospitals, and lack of adequate community care, among others. It also seeks to improve access to healthcare and to improve eHealth (electronic health) in the country.

Sláintecare as originally envisaged also seeks to move away from the national body of the HSE to establish six Regional Health Areas across Ireland, with each one responsible for its own budget and care delivery.

To do all this requires a significant system change in how Irish healthcare operates.

How is it progressing?

Following the publication of the Sláintecare report, opposition politicians were critical of the slow progress in moving forward its recommendations.

In August 2018, the then-government published the Sláintecare Implementation Strategy (SIS), which set out a 10-year framework for the implementation of key reforms to the healthcare system.

The Sláintecare Programme Office (SPO) was set up to oversee this implementation and the Sláintecare Implementation Advisory Council (SIAC) was set up to advise the SPO.

A number of high profile figures were appointed to the SIAC. Dr Tom Keane – a notable leader in the field of cancer research who led the overhaul of Ireland’s cancer services between 2007 and 2010 – was the chair.

Laura Magahy – a design and project consultant who has been involved in a number of significant public sector projects over the past 30 years – was appointed as the executive director.

According to Dr Sara Burke, assistant professor in the Centre for Health Policy and Management at Trinity College Dublin (TCD), who has worked extensively on Sláintecare research, initial progress of reforms was slow, but implementation began to ramp up in late 2019 and early 2020.

“By the end of 2019/early 2020, we were beginning to see momentum,” said Burke.

“For example there were one thousand extra staff flagged [for Sláintecare] in Budget 2020, which was announced in October 2019. That was the first time there was anything like the investment as originally envisaged in the 2017 report being delivered on.”

In its progress report for the implementation of Sláintecare in 2019, the Department of Health said that 138 projects had been progressed, with 112 of them on track, 24 facing minor challenges, and two facing significant challenges.

Overall, Burke said that the investment or the staff weren’t made available to fully implement Sláintecare, but that before the pandemic, things were improving.

“Then the pandemic happened and obviously everything was deflected onto Covid. Everybody had all hands on deck for a once-in-a-century pandemic and that was quite understandable,” she said.

Covid-19

Covid-19 saw the Irish healthcare system – and all of Irish society – switch into emergency mode, as the nation faced unprecedented challenges. While the system was put under immense strain, and waiting lists (which were already high) skyrocketed, a number of positive initiatives were put in place.

“I think one of the things that happened with Covid was that the system was given money and freedom to innovate, and because there was this big push to keep hospitals free for Covid surges, lots of innovation has occurred across the system,” said Dr Burke.

“What we saw during Covid was the health system under huge pressure, but actually coping pretty well and also loads of innovation and change on the ground.

“So I think our Covid response has shown us that we can do huge health system change very quickly.”

Budget 2021 saw a significant increase in health spending, as the government poured money into fighting Covid-19. Of the €4 billion extra in health funding, €1.35 billion was dedicated to implementing Sláintecare initiatives.

In May 2021, the government published its Sláintecare Implementation Strategy & Action Plan 2021-2023, which included details on 11 significant projects to increase capacity in the community, to address waiting lists, to provide management of chronic diseases outside hospitals, to empower patients, and to innovate in the area of eHealth, among others – all key areas of Sláintecare.

In her forward to the strategy, executive director Laura Magahy said that “steady progress has been made in implementing key reforms”.

“With the goodwill, funding, and implementation focus that has been built up for Sláintecare, collectively we have the opportunity over the next three years to implement Sláintecare at pace and continue to translate the Sláintecare Report from shared vision to reality.”

Resignations of key figures

Just four months later, however, Laura Magahy resigned her position as executive director of SIAC. In her resignation letter, she cited slow progress in three key areas of the Sláintecare reform: the regional health areas; eHealth, and waiting lists.

Soon after, Dr Tom Keane – the chair – also stepped down, stating that “the requirements for implementing this unprecedented programme for change are seriously lacking.”

Later that month, gastroenterologist Professor Anthony O’Connor also stepped down from SIAC.

In his resignation letter, O’Connor said that “fundamental failures of governance, accountability and commitment continue to make any chance of success impossible”.

“It is now clear to me that the culture of collaboration, respect, community and engagement that had been envisaged by the Sláintecare report has been bulldozed.

“What has been chosen by Government to replace it is entirely incongruous with the principles of the project.”

Following these resignations, SIAC was disbanded by Health Minister Stephen Donnelly in October, with a new Programme Board established to oversee the implementation of Sláintecare projects.

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This Programme Board is co-chaired by the Secretary-General of the Department of Health Robert Watt and the CEO of the HSE Paul Reid.

Progress since the resignations

The Sláintecare progress report for 2021 outlines for progress of the 11 key projects, broken down into 228 “deliverables”. According to the report, 146 deliverables were on track, with 54 facing minor challenges and 28 facing significant challenges.

A number of key reforms – including plans to reduce waiting lists – were facing significant challenges at the end of 2021. Certain areas – like removing private care from public hospitals – had been progressing at the beginning of the year, but stalled in the second half.

This week, the Department of Health announced the establishment of new Regional Health Authorities, one of the key elements of Sláintecare reform. However, according to a briefing from the Department of Health reported this week in the Business Post, the new RHAs will not have their own boards and will be answerable to the HSE.

While health experts state that Sláintecare reform is progressing at a slow pace, the government has been accused on a number of occasions of “cherry picking” certain reforms and disregarding others.

“The original report is hugely transformational of the whole system, it’s a big project. I often describe it to students when I’m teaching, as if you look inside a clock and you think of all the cogs and pieces that have to turn together to make a clock tick – I think it’s a useful way to think about health systems,” says Dr Burke.

“So for example hospital waiting lists – the biggest delay in accessing care is that delay with an outpatient specialist… You can wait months or often years before you get to see that specialist.

“In order to fix that problem we need more specialists in the hospital, but we also need many more, say, nurses and physios and occupational therapists working in the community.

“Because if we have them working well in teams at a community level, then lots of people won’t have to end up going to see that specialist in the hospital if they get that early intervention and care.

“So there are lots of different wheels that need to turn to fix the system rather than just: we need more doctors in that hospital. And that’s the whole system bit. And that’s the problem with cherry picking.”

This work is also co-funded by Journal Media and a grant programme from the European Parliament. Any opinions or conclusions expressed in this work are the author’s own. The European Parliament has no involvement in nor responsibility for the editorial content published by the project. For more information, see here.