In 2018 I received an invitation from Minister Simon Harris to join the Sláaintecare Implementation Advisory Council (SIAC), the first meeting of which was held in April 2019. During the introduction I made clear my interests and focus on hospital reform , but was informed that the advisory council would not be getting involved in anything “too political”.
In subsequent presentations and reports to the SIAC it became clear that hospital reform and the reorganisation of hospital groups to align more effectively with community health organisations was well down the priority list of the implementation programme.
At subsequent meetings every four months, lasting two hours, the agenda comprised a report on the “progress” of the implementation programme as well as various presentations on topics such as “people engagement” and “wellness”. Some of the meetings involved “focus” groups, beloved by the HSE and Department of Health.
The advisory council were never asked for its advice on the direction or speed of travel of the Sláintecare programme, and some members shared my view that the council was just “window-dressing”.
For example, when the appointment of the HSE board and the signing of the new GP contract were listed as Sláintecare achievements many of the council members felt it was meaningless because those issues had been ongoing prior to the announcement of Sláintecare.
In September 2020, following the second Covid -19 surge, Minister Donnelly announced that on the advice of the HSE, which he supported, all aspects of hospital reform would be put on hold for one year until 2022 at least.
At the spring 2021 meeting of SIAC, the chair expressed serious concerns about clinical governance in Irish hospitals, and the June meeting was dedicated to a discussion on clinical governance in our hospitals and community organisations.
The proposed Sláintecare consultant contract was a second item on the agenda as requested by a member of SIAC. However, following a lengthy discussion on governance there was insufficient time to discuss the contract. A proposal for a special meeting with a single-item agenda was agreed, but in a letter to the SIAC in August, the chairman indicated that there would be no additional meeting because the new public-only Sláintecare consultant contract was already Government policy and not for discussion.
Reaction
I had been considering my position on SIAC for several months prior to that time as I considered, like several other members, that the SIAC meetings were largely a waste of time.
I was not prepared to be associated with an organisation promoting a public-only consultant contract, and therefore resigned my position on SIAC approximately six weeks before the chairman and executive director.
The reaction and fallout from the resignations of the Sláintecare leadership has been significant. Tom Keane, the chairman, was clearly frustrated by the lack of tangible progress and presumably could see no significant improvement in political support. In his role as leader of the Cancer Reform Programme in 2006 he enjoyed the powerful and very visible support of Minister for Health Mary Harney.
Meanwhile, like any project director, Laura Magahy presumably wanted to show evidence of progress of the Sláintecare programme. An editorial in this newspaper three years ago identified the risk of “cherry-picking” parts of the Sláintecare programme if overall progress was slow. The prediction came true.
It is difficult to assess at this point whether Sláintecare and its implementation can be even partially resuscitated.
The project work in the community has had an impact, and, paradoxically, the adaptive approach of the GPs and primary care teams during the pandemic implemented many of the Sláintecare concepts in keeping as much care as possible locally and referring only the sickest patients to hospital. Retaining and supporting those teams and their work and improving local access to diagnostics will be important, although there are serious challenges in recruiting the necessary additional staff.
Repercussions
The major challenge is the hospital system and the lack of impetus to reform hospital structures because of fear of political repercussions. If Sláintecare is truly an initiative with total cross-party support then individual local politicians cannot adopt the “not in my backyard” approach when it comes to a well thought out reconfiguration of services which, in the opinion of experts, will provide safe care to the local population.
Empowering local regional health authority (RHA)boards and their executive teams to reorganise hospital services, both emergency and elective, in their geographically-defined areas is the only way to progress this major component of the Sláintecare programme. As yet the necessary legislation does not exist even in draft form.
Furthermore, instead of using the usual Dublin, Cork and Galway model for the proposed new elective hospitals why not assign them to the RHAs who, following the reconfiguration of their hospitals, are identified as the least well off in terms of elective capacity.
Conflict between the Sláintecare leadership and the HSE over who was to have control of waiting lists is another suggested reason for the resignations. Whether that is true or not, in the short term the private hospital sector will need to help with the large waiting lists which many are predicting will hit the million mark before the end of this year.
Private hospitals themselves are under pressure with a backlog of elective activity due to Covid-19, but some arrangement similar to the “Safety Net” agreement between the public and private systems that pertained during the pandemic would give uninsured patients improved access to elective procedures. There are already pilot programmes of this arrangement in some areas of the country with immediate benefits to public patients on long waiting lists.
Medical expertise
Finally, and with regard to the so-called Sláintecare consultant contract, we will need all of the available surgical and other medical expertise in the coming years, and now is not the time to impose a contract on our young consultants that will keep them “locked in” to the public hospital when even the largest of those hospitals do not have sufficient resources to keep their expert staff busy and productive throughout the entire week.
Let’s leave ideologies aside to ensure that all patients have timely access to our highly-skilled consultants that we, the taxpayers, have paid to educate and train.
Let’s stop the nonsense which can only result in a new kind of two-tier system where consultants are forced to choose between the public and private system, and where patients could be possibly deprived of expert care in certain disciplines.
A revived, modified Sláintecare programme with insightful leaders who listen to those who know and understand what works in their respective areas may provide the answers, but the advice is still not to hold your breath!
Patrick Broe is group clinical director of the RCSI Hospital Group