No sooner was the Sláintecare implementation plan published when it started. The nurses said it would all collapse if the issue of their “inadequate pay” was not sorted out. The consultants warned more cash was needed for beds, frontline staff and, eh, more consultants.
The Irish Medical Organisation wanted "urgent and sustainable investment" to stabilise the current system before any reforms, and the National Association of General Practitioners said it all "smacked of empty rhetoric", and accused the Government of no meaningful engagement on their new contract since last November. And the Private Hospitals Association said its members could help to deliver the new beds that were needed.
And so it goes on.
Simon Harris has published his implementation plan for Sláintecare, ditching some of the proposals of the original strategy drawn up by an Oireachtas committee, but keeping much of the core of this approach. But there is no funding commitment in the implementation plan, clearly indicating that the fight for budget resources has still to be won.
The risk now is that this whole things is scuttled by a prolonged standoff – within the Government and between the Government and the HSE.
The lack of costings in the Sláintecare implementation programme points to something of a breakdown in relations between the Department of Health – and the HSE– and the key centres of power in the Department of the Taoiseach and the Department of Finance and Public Expenditure.
Waiting lists
The annual overruns in the health budget are as predictable now as the arrival of the first swallow. Despite the additional cash – amounting to a 19 per cent spending increase since 2013 – Ministers see the ongoing failure of the HSE to deliver in terms of cutting waiting lists and operating a properly-functioning emergency care system. This has undermined confidence in those who manage the exchequer’s purse-strings and make the key calls on where resources are allocated.
And so the Sláintecare programme is published without a budget, and Harris is left to bat with sceptical Government colleagues on one side and the HSE and the health lobbies baying for extra cash on the other.
And cash is not the only issue to be sorted. A special group has been set up to examine the thorny issue of private doctors working in public hospitals. If you think the legal profession put up a fight on the legal reform Bill, just wait till you see the consultants on this one.
I am not an expert in the health sector, but I have been around long enough to see dozens of official plans to reform and change things come and go, too often with little real impact.
We seem to have a problem implementing significant long-term change programmes.
They do not suit our electoral cycles, our clientelist politics or the hold which vested interests seem to have in blocking reform.
We are at risk of a stand-off rather than a real effort to get wind behind the latest reform plan
The direction of the Sláintecare plans seems to be guided by common sense and by the kind of things we have been saying for years that we need – better and more organised community care, a modernised acute care system and a move away from the two-tier private/public system towards universal provision.
Yet it is only when there is cash behind it all that we will see a real political commitment.
Accountable
We have had administrative deck chairs – a plan to abolish the HSE, then the canning of its board, before now we get the board being reinstated. Perhaps this is a good idea, as may be the appointment of a team to implement Sláintecare led by Laura Magahy and with an advisory council chaired by Dr Tom Keane. With a Minister, a department secretary general and a HSE chief executive also in the mix, someone is going to sort out who is responsible – and accountable – for what.
Otherwise the risk is that the whole thing gets stuck again in the usual mélange of finger-pointing about who was meant to do what. We have a plan with all the timelines and deadlines, dressed up in the jargon de jour of high-impact actions, strategic actions and sub-actions.
But this is all about implementation, getting momentum behind change and being seen to deliver a few early improvements. And this will require cash – and support from all areas of Government.
Trust has been undermined because HSE overspending has been endemic in recent years. Since 2014 cumulative overruns exceed €2 billion – though some relate to political decisions and not all to budget busting.
A quick scan through the archives reveals at least three occasions when “no more overrun” warnings have been issued to the HSE. But when the price of keeping to the budget involves closing wards or lengthening queues, then the HSE and the hospitals, which are the source of much of the overspending, know they have the politicians over a barrel.
Reform plan
And so we are at risk of a stand-off rather than a real effort to get wind behind the latest reform plan. Health spending is over-budget again, and is 8.5 per cent ahead of last year. Minister for Finance Paschal Donohoe rather pointedly told the Dáil recently that more than 1,500 staff had been recruited this year. Yet we can't go on with the old story of annual overruns and no change.
This is the only plan we have. It came from a cross-party group, and so has some chance of wider political acceptance. It should be given a chance, with terms and conditions involving budgets and delivery applying to those in charge.
But if this is caught up yet again with the general election cycle and party political claim and counterclaim, then any chance of progress will – yet again – be lost.