More than three weeks after the two key figures tasked with implementing Sláintecare resigned, the fate of the all-party plan for the future of the health service continues to hang in the balance.
This week, the advisory group set up to assist the reform process may follow Laura Magahy and Prof Tom Keane out the exit door when their term of office ends. Members of the Sláintecare Implementation Advisory Council have sought an extension of their term to Christmas because of the crisis provoked by the resignations. Minister for Public Expenditure and Reform Michael McGrath said the Government will consider the request.
The council is due to meet Health Service Executive chief Paul Reid and Department of Health secretary general Robert Watt on Monday, but it remains to be seen whether this meeting proves any more productive than its session last week with Minister for Health Stephen Donnelly.
That was dismissed by council members as a “farce” in which no insight was provided as to the reasons for Magahy’s and Keane’s departures.
The council was set up by the department three years ago to bring expertise and an independent perspective to the reform process. Last week, members were at one point forced to organise their own Zoom meetings due to the unavailability of secretarial support.
“We were left floundering in the dark,” one member fumed. “The treatment of council members by the department shows scant regard for the sacrifices made by very busy people, leaving their vital work to attend meetings. It is unacceptable.”
But members, who strongly backed the proposals from Magahy and Keane for the regionalisation of the HSE, are also irked with the pair over the manner of their sudden departure.
“They never told us things were anywhere near bad enough to force their resignations prior to the event,” one council member complained to colleagues during the week, adding: “Their communications with us since their resignations have been brief and perfunctory.”
The two departing officials explained the reasons for their resignations in brief letters to the Minister, but gave no advance notice to the council. Keane said “fundamental failures of governance, accountability and commitment continue to make any chance of success impossible”. Magahy cited “slow progress” in three key areas: the proposed new regional structures, e-health and waiting lists.
With Magahy working out her notice, she may feel constrained in explaining what led to her decision. Keane is thought to be keeping his powder dry for an appearance before the Oireachtas health committee, but this won't happen until October 6th, less than week before the budget and after the council's term is up.
Budget 2022 will see health endowed yet again with record amounts of funding – but no clear plan for reform of the sector and no leadership for this process.
So far, this controversy has been dominated by the divergent views of individuals, the rivalry between Sláintecare officials, the department and the HSE, and the eternal tension between reformers and conservatives. There was an inevitability about the recurrence of the turf wars that have marred health planning for so long, and which Sláintecare was supposed to banish.
The disagreements have also highlighted how little detail there is in relation to the plan, four years after it was published. It is difficult to benchmark progress on regional structures, for example, when so little published information is available on what the Government intends to do.
While the Fine Gael-led government then in power was officially backing Sláintecare at the time of its publication, then minister for health Simon Harris was highlighting reservations with the all-party report in a confidential memo to cabinet in July 2018. Some of the timelines laid down for reform in the programme were "unrealistic"; the report did not highlight some of the essential preparatory work needed; and it failed to deal with prioritisation, sequencing and other implementation issue, the memo said.
Describing the HSE as “both arguably too big to fail and too big to succeed” Harris asked cabinet to start the ball rolling on reforming the health system. This was to include a more strategic centre to carry out national level functions, with new regional bodies to support delivery of integrated care.
The memo said Harris “broadly” supported the regionalisation proposals in the report “recognising the value of geographical alignment for population-based resource allocation and governance to enable integrated care”. However any change would have to be based on minimising disruption to service delivery.
A year later, Harris announced the establishment of six new regional bodies to operate hospital and community services. He launched a map of the new geographic areas. Again, the precise details on how these would actually operate remained to be determined.
Last week Donnelly told the Dáil that work was at an advanced stage in his department on selecting a preferred “model” of regionalisation for submission to Government for approval. There are varying views on the nature and role of these new regional structures and how they would work in practice, given all the other moving parts in Irish health administration.
Widespread analysis has been conducted both in the Sláintecare programme office and more broadly in the department, with the assistance of outside consultants, EY.
Briefing material prepared for Donnelly on his appointment in summer 2020 suggested the EY report was imminent. However neither it or other background material have been published and it is unclear whether they were ever shared with the Sláintecare Implementation Advisory Council.
Informed sources said in determining the preferred model, key questions would have to be answered, including what would the HSE centre look like in the future? And how would a balance be achieved between ensuring consistency in services across the country against local responsiveness to particular needs and demands?
At present the department is responsible for policy, and the HSE is responsible for running services at an operational level. How would these roles work under any reformed system with regard not only to policy but also to strategy, clinical leadership, the provision and analysis of data, and oversight?
The role of State-funded voluntary organisations that provide large portions of hospital and disability services would also have to be factored into the reforms. And would new regional bodies be established on a legislative basis – which sources say would be very important for clinical governance – or on an administrative basis?
Finally there is the crucial matter of autonomy. How much freedom would the regional bodies have in spending, particularly on staffing? How likely is it that the Department of Public Expenditure would allow regional bodies to decide on pay, for example for hospital consultants, potentially undermining its carefully-established national arrangements for determining remuneration across the public service?
At present local hospitals have autonomy on staffing, to fill replacement posts – with the exception of hospital consultants – in cases where the position has been recently vacated and is considered to be “funded” within budget.
There are additional controls on the appointment of consultants. Replacement posts have to be discussed at group level, and new consultant positions have to be approved by the HSE. There is no local autonomy in relation to pay. All managers at local and national level, including voluntary sectors, are required to adhere to public service pay policy set out by the Department of Public Expenditure.
Many observers and academics believe existing structures in the health service are unwieldy and need to be overhauled. Six hospital groups cover various parts of the country, while there are also nine different healthcare organisations overseeing community and primary care services. All have their own management structures. Their geographic boundaries do not align.
There is also a variety of different voluntary healthcare providers in both the hospital and disability sectors, each with their own boards and management. Convoluted administrative reporting relationships can be found across the sector.
The Sláintecare reforms are not just about establishing new regional administrative systems. The plan involves fundamentally changing budgetary arrangements. Historically, health budgets have been based on the government giving a little more or a little less than the previous year, according to Dr Sara Burke, research assistant professor of health policy at Trinity College Dublin. Under the proposed reforms, budgets in the regional bodies would be allocated on the basis of demographics, health needs, levels of deprivation and specific geographic issues.
Burke believes important benefits will flow from aligning hospital and community services into one structure. “Currently, where a patient is in a hospital but does not need to be there – a delayed discharge – there is nothing to motivate the hospital to discharge them or for the community organisation to take them.”
There is very good evidence about how financial incentives and funding models could shift care delivery, she says.
The controversy of recent weeks has raised doubts about the Government’s commitment to these kinds of complex reforms. On the other hand, Ministers, when they do show their hand, may argue that the reforms can be pushed through by traditional health structures rather than the additional layer created by Sláintecare.