Progress has been slow but Slaintecare supporters still believe it will deliver reform

Capacity of system his been enlarged and reforms have begun - but the move to a single-tier health service seems as far away as ever

“I’m hopeful, I have to say. It’s moving at a slower pace, but I think we’ll get there in the end,” says Roisin Shortall, co-leader of the Social Democrats, and one of the architects of the Slaintecare plan.

“We’ve made huge strides in our ambition for universal healthcare,” says Stephen Donnelly. “High quality, affordable healthcare that you can access when you need it.”

“Slaintecare? Slainte-who-cares?” says a senior figure in the Department of Health.

“Look, Slaintecare means different things to different people,” explains a senior official. “It’s your flexible friend.” Some of the things are going well, the official notes. Some of them are not going at all.

It’s five years since the Oireachtas all-party committee produced its 10-year plan to reform the health service and transform it from a two-tier service, in which patients who pay for private health insurance often receive speedier and better care than those without, into a single-tier public system providing universal access to healthcare based on need. It has polarised opinion from the start.

Some politicians – wholly in favour of its aims and reforms – were sceptical that a health service so dominated by sectional interests, each with a record of jealously guarding their own position, would be capable of treading a path of radical reform.

Other politicians, including some involved in drawing up the plan, doubted that it was either possible or sensible to seek to separate completely the stuttering public health service from the flourishing private sector.

Senior officials wondered privately (and sometimes not so privately) if Fine Gael and Fianna Fail would squeeze private health insurance – held by many of their voters – out of the system. Others in the Department of Finance worried a lot about the costs of the plan.

Half a decade after the Slaintecare plan was agreed and published, doubts and worries persist. As do questions about a lack of progress. But even those who are most critical of successive governments’ commitment to the plan say that in some elements of the Slaintecare reform plan, a lot has been achieved.

Most obviously, there has been a dramatic increase in funding, as the health system expanded to deal with the threat of Covid. It will retain a lot of extra annual funding. Nobody disputes some aspects of the healthcare system remain drastically inadequate, but the overall capacity of the health service is expanding quickly.

However, the most arresting and controversial objective of Slaintecare – the separation of public and private – has seen little if any movement. Private healthcare will be part of the Irish health system for the foreseeable future. A single-tier health service seems as far away as ever.

The Slaintecare plan was the result of an all-party committee set up in the wake of the 2016 general election, and a shared political concern that the health system, battered after the years of austerity, needed a new direction and a new departure. As party leaders wrangled over the formation of a government – eventually settling on the confidence and supply arrangement that saw Fianna Fail facilitate a Fine Gael-led government with independents – a group of TDs busied themselves for a year in designing a plan for the future of a radically different and more efficient health service.

The chair was Roisin Shortall, co-leader of the Social Democrats and who had, as a Labour junior minister in the previous government, resigned over differences with the Fine Gael health minister James Reilly. Reilly was only the latest in a long line of health ministers promising to fix the misfiring health service who ended up limping off the field. Shortall’s committee beavered away for a year and overcame its own internal divisions to produce a lengthy blueprint for a new healthcare system, to be implemented over 10 years.

It included reforms that people had been talking about for ages, such as expanding primary care in order to take the pressure off acute hospitals. It also had a focus on reducing the cost of healthcare to ordinary people, recommending the elimination over time of many of the charges that people pay at all levels of the healthcare system. And it had a novel element – the complete separation of the public and private systems.

People had long complained about the injustice of a two-tier system of healthcare, where those who could afford private insurance were able to access treatment more quickly, treatment that was often delivered in healthcare facilities funded by the taxpayer, and by doctors who were paid by the taxpayer.

At the same time, about 50 per cent of the population was covered by private health insurance; they were also taxpayers who were paying for the public facilities. Ireland’s unusually large private healthcare system was interwoven at all levels with the creaking public system. Now, for the first time, there was a serious plan to separate them. Building an improved public system, the report argued, would convince people that they did not need private health insurance. So they would not object to the removal of private care from public hospitals. That, at least, was the theory.

The report was endorsed by all parties, but it was, Shortall now says, “very slow to get off the ground”.

She was disappointed when the recommendation to establish an office to oversee implementation of the report in the Department of the Taoiseach was ignored, and situated instead in the Department of Health. But the new Minister for Health, Simon Harris, was enthusiastic and secured the appointment of Laura Magahy, once head of Temple Bar Properties and a longtime operator in both state and private sector, and Tom Keane, who designed the reform of cancer services in the 2000s, to help with the transformation project. But both resigned last year, amid the widespread belief that they were unhappy with the Government’s commitment to Slaintecare.

By then, Stephen Donnelly was health minister; he continued to protest his commitment to the project, but Shortall and others were sceptical. Department of Health Secretary General Robert Watt and HSE chief executive Paul Reid now oversee implementation.

The health service, of course, had other challenges in recent years. From February of 2020 until earlier this year, the service was turned upside down as it struggled – just about successfully – to cope with the pandemic. With non-Covid treatments suspended, waiting lists exploded. But so did funding – the increase in 2021 was €4 billion – and it is now accepted across the political system that much of the quantum leap of funding the health service received during the pandemic would be retained, providing a giant boost in resources for a service that had always complained of being underfunded, and frequently ran out of cash before the year ended.

“In some ways,” reflects one senior figure, “Covid helped”.

Shortall also says that when the system was under maximum pressure, it moved quickly towards a single-tier system. “Imagine if we had a two-tier approach to testing and vaccines,” she says. Reid described it as “Slaintecare on speed”.

Only for a time, though. As the pandemic receded, the previous structures returned. The combined public-private mix is central to shortening the enormous waiting lists for treatment that are another of the legacies of Covid.

So private medicine remains a central part in Ireland’s public health system. Most of the senior figures across Government, including several directly involved in the project and who spoke to The Irish Times for this article, were intensely relaxed about this, with few viewing the separation of public and private as a priority. But the lack of progress on this Slaintecare objective should not mask the significant changes that are underway in the way the health system is organised and many are themselves essential parts of its reform plans.

The first of these is the most basic – the significant expansion in the size of the health service. Figures from the Department of Health show that it has hired thousands of additional staff since early 2020, with almost 15,000 more now working in the service.

This includes, the department says, 4,200 nurses and midwives; 2,500 working in patient and client care in roles such as healthcare assistants and home helps; 2,300 health and social care professionals; and 1,300 doctors and dentists. It adds that 2020 and 2021 saw the biggest staff increases on record since the HSE was established. More beds and more ICU beds have been opened. Ireland’s health service is now significantly bigger than it has ever been.

There has also been a lot of money spent making care cheaper for the people who need it, reducing or eliminating charges. Drug payment thresholds have been reduced, meaning that those who need medicines pay less for them, with the State picking up the rest of the cost.

Last week, Donnelly announced he would remove hospital charges for children under 16 who attend a public hospital as an inpatient or day case; he has previously said he wants to remove adult charges. Free GP care has been extended to children under 6, and the Government says it wants to extend to the under 8s later this year. The law allows it to be extended to the under 12s.

Community care has been expanded – a vital part of the plan to take pressure off hospitals. The Department says that 81 community healthcare networks have been established since 2021 with over 1,850 staff already recruited.

The holy grail of an “integrated care system”, where all stages of a patient’s care are connected and are talking to one another, is some way off; but it’s a lot closer than it was. “It’s about shifting care to the community and we’re doing a pile of that,” says one person involved. Everyone concedes that its not making a difference quickly enough. But it is making a difference.

Structural reforms such as the regionalisation of the HSE and the hospital groups has been slower. Reid and other senior officials didn’t want to do it during Covid, but planning for the move – which will involve budgets and management being devolved to regional authorities – is well underway.

One senior source warns that the move is likely to be delayed by Reid’s departure, however. “That’s what we hired him to do in a way,” said one politician. Others see political difficulties down the line when some regions inevitably feel others are being favoured.

“Look, regional authorities are not an end in themselves,” says one senior official. “The end is to be able create integrated care pathways.”

But the biggest enabler of the Slaintecare reforms, said almost everyone who spoke on the subject this week, is a new contract for hospital consultants that would restrict them to working only in the public sector. At present, many consultants retain lucrative private practices which they serve in private hospitals or, in some case, in public hospitals. A new contract, under which hundreds of new consultants would be hired and under which they would be employed exclusively in the public hospitals to treat public patients, would be a gamechanger, sources say.

Negotiations, stalled for months, began again last week. One senior figure is optimistic they can be concluded in 3-4 weeks, but others are not so sure. The salary offered will be in the region of €250,000 a year – enough, the Department of Health hopes, to entice home many consultants who work abroad, and maybe even persuade some holders of existing public-private contracts to switch. Maybe, say observers. Maybe not.

“It all hinges on the consultants’ contract,” concludes one high-ranking source.

If the new contract is agreed, and the recruitment of hundreds of consultants takes off – there are about 700 vacant posts at present – insiders say that the gradual separation of public and private will commence. It won’t happen overnight. But in another 10 years, there would be a lot less private medicine in public hospitals.

“The two tiers are not the problem. The two tiers are a response to the problem. The problem is the lack of capacity,” says one official.

“Total separation is unlikely,” adds another. “And not necessarily desirable.”

Even Roisin Shortall is sanguine on the pace of separation, saying some practices will simply be “grandfathered out” – they’ll decline as people retire.

She is more optimistic about Slaintecare than she has been for a long time. The Oireachtas health committee has requested that Watt and Reid appear before them every three months to report on progress. Some of the meetings have been a little spiky. “Three weeks ago for the first time I felt with these guys – we are making progress,” she says.

Asked how far along the whole project is, Shortall reflects: “It’s a 10-year plan. Are we halfway there? No, we’re not . . . We’re probably one third of the way along. But increasingly people are realising this is serious. This is the only way. There’s no plan B.”

Pat Leahy

Pat Leahy

Pat Leahy is Political Editor of The Irish Times