Sláintecare resignations leaves HSE to drive healthcare reform

At the heart of the resignations of Laura Magahy and Prof Tom Keane – the two most senior people responsible for Sláintecare – is that they were expected to be responsible for implementing and advising on Sláintecare but without the actual authority to deliver it.

The 2017 Oireachtas Committee on the Future of Healthcare Sláintecare report set out a 10-year health reform plan, unique as it was devised through cross-party political consensus. At its core is the aim of universal access to timely, quality, integrated care. Executing major health system transformation such as Sláintecare requires strong political and health system leadership, sufficient resources (both people and money) and sustained implementation overtime that is supported at all levels.

Government was slow to adopt Sláintecare, taking 15 months before making it government policy. And when it did, it was done on their own terms with a watered-down implementation strategy and the establishment of the Sláintecare implementation office in the Department of Health, not the Department of the Taoiseach as originally envisaged. Sláintecare survived last year’s change of government, featuring in the 2020 programme for government. Yet, the resources required to fully implement Sláintecare were notably absent in its first three years of implementation.

Delivering large-scale reform such as this is akin to changing the direction of a huge aircraft carrier. By early 2020, Irish health policy was being steered in the right direction, with many of the essential foundations to deliver Sláintecare’s reform being put in place by Magahy’s team. Central to universal access is providing much more care in the community, with seamless care pathways and making access to the public hospital system an even playing field, through phasing out private care in public hospitals. This is to ensure that patients get the care they need, when they need it, without cost as a barrier.

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Waiting lists to access essential diagnosis and treatment in the community and in hospitals are the most problematic feature of the Irish public-health system

Sláintecare’s progress was stymied by the arrival of Covid-19 as all but essential services were closed, community and hospital waiting lists grew and many staff were redeployed to the pandemic. What also emerged was that many of the Covid-19 health system responses were inherent to Sláintecare – significant ehealth investment, new care pathways, a big push for more care outside of hospital, clear and strong public-health messaging, investment in more staff and services, with universal access to all Covid-19 testing, diagnosis and treatment, free at the point of delivery.

Implementation strategy

This year’s budget saw the biggest ever investment in health, with much of this earmarked for pandemic management, alongside the most significant Sláintecare allocation since its inception. In May of this year, the Government approved the Sláintecare Implementation Strategy and Action Plan 2021-2023, which charts the specific progress needed for whole system change.

In her letter of resignation in early September, Magahy cited frustration with “slow progress” in three key areas – the regional structures, ehealth and waiting lists.

In the 2017 Sláintecare report, the rationale for the regions are made clear. Acknowledging the disruption caused by system reorganisation, it recommends “structural change should be as simple as possible”. The purpose of the regions is to facilitate the allocation of health resources on the basis of population health need and to enable integrated care delivery, with clear management and clinical governance and accountability.

The Health Service Executive cyberattack is both a cause and consequence of the slowness to move on ehealth. Despite detailed plans in place, adequate financial and staff resources are yet to be allocated to enforcing ehealth, which is one of the most important mechanisms to enable major health system change.

Waiting lists to access essential diagnosis and treatment in the community and in hospitals are the most problematic feature of the Irish public-health system. Without eliminating our extraordinary long waits for care, universal access remains elusive. Tackling waiting lists requires a sustained, multi-annual budget and whole-system approach. Plans to remedy waiting lists remain unpublished with no one taking charge for tackling this specific issue.

HSE reorganisation

The HSE has, against the odds, proven itself capable in its Covid-19 response. In recent months, the HSE has quietly reorganised its own senior tier, indicating an unwillingness to let go of its centralised command and control structure and an inability to deliver on the long haul that is major health system change.

If the Government really supports Sláintecare then it needs to get 100 per cent behind it

Magahy and Keane would not have resigned if they had the political and institutional support to realise Sláintecare. Most progress made to date can be attributed to their leadership. Yet there is no urgency about their resignations from our political or health system bosses. The greatest risk now is that we do what we have always done in health – continue with risk adverse, incremental change. Leaving responsibility for Sláintecare’s implementation to the Department of Health and the HSE will most likely result in cherry-picking of parts of reform that suit or are easier to do but critically ignoring the hard, radical whole system change needed to deliver a universal health system. Such inaction may well suit some people throughout the health system who profit from the maintenance of the status quo.

The 1989 Commission on Health Funding observed that “the simple question ‘who is in charge’ of Irish healthcare cannot be answered”. Thirty-three years on, this is more pertinent than ever. If the Government really supports Sláintecare then it needs to get 100 per cent behind it, provide clarity on who is in charge of driving Sláintecare, specify clear lines of clinical and managerial responsibility and governance for implementing the plans for the regions, ehealth and waiting lists.

Failure to do this means Ireland remains a complete European outlier without universal access to care based solely on medical need. Ultimately, it is the Irish people who would bear the brunt of Sláintecare’s demise. Surely we deserve better.