Many of the worst problems that exist in the Irish health system are a direct result of choices Irish political leaders have not made. Key decisions delayed, avoided or opposed due to political cowardice and an absence of vision.
The failure of government to respond, act and implement Sláintecare, the cross-party consensus plan for health reform, stinks of similar obfuscation. Speaking in Kerry on Wednesday after an extended Cabinet meeting, Taoiseach Leo Varadkar said "while we accept the Sláintecare report . . . we're already spending a lot of additional money on healthcare . . . It is difficult to find even more money on top of that to implement other programmes . . . Some things will have to be done at a slower pace than maybe people would like."
The word emanating from Leinster House over recent weeks is that Sláintecare is being stalled by the Department of Public Expenditure and Reform, which is opposing any allocation of money for Sláintecare on the basis that the Health Service Executive has overspent. It wants any additional health money going to mop up this overspend, rather than investing in Sláintecare.
Such a position perfectly demonstrates the short-sightedness of the department. As long as we keep on providing care in the system riddled with perverse incentives, which push people into hospital – the most expensive place to get care – there will always be overruns.
Sláintecare maps out a route to a very different type of health system, with a much greater focus on strengthening the public’s health, much more early intervention and prevention, the management of the majority of illness outside of hospital in a functioning, integrated primary and social care system. A more efficient system that meets people’s needs, where care is not denied due to barriers of cost and long waits, where public hospitals treat everyone on the basis of medical need, not on their private health insurance status.
Healthcare professionals
In order to move to this system, additional investment is required. This includes training and hiring more healthcare professionals, properly investing in eHealth, providing diagnostics in the community and sufficiently resourcing primary care. This cannot be done within the existing budget.
The department is kicking it to touch by saying that the funding required for Sláintecare will be dealt with as part of the annual budgetary process, which fundamentally ignores the case Sláintecare makes for additional investment. But the department is not the only obstacle, Government has been slow from the start on Sláintecare.
Making Sláintecare happen requires leadership, courage and vision from Varadkar, Donohoe and all of government, where they focus on the important rather than always reacting to the urgent
Sláintecare was published on May 30th, 2017, two weeks before Varadkar became taoiseach, when Simon Harris was just months into the health ministry. Sláintecare set ambitious timelines for an implementation office to be set up by July 2017, a detailed implementation plan to be published by December 2017. Harris promised a government response by Christmas, then Easter, then the summer recess. Each of these deadlines has been missed.
International evidence shows that bringing about major health system change is extremely difficult without leadership from the very top, including support from the finance ministry.
Given the policy context of Sláintecare, the absence of a special breakout group on health in the recent National Economic Dialogue was striking. At that dialogue, the Taoiseach spoke about how Ireland’s high spend on health was hard to justify. Recent Varadkar tweets focused on how some hospitals are managing to bring down waiting times for care. These views demonstrate a leader reverting to Fine Gael’s ideological form, thinking that old-style managerialism and efficiencies can fix our health service.
Greater efficiencies
Of course, the Irish health system can and should be better managed, with greater efficiencies, better accountability, transparency and governance structures. These are among the Sláintecare recommendations.
Making Sláintecare happen requires leadership, courage and vision from Leo Varadkar, Paschal Donohoe and all of government, where they focus on the important rather than always reacting to the urgent.
Last week's appointment of Laura Magahy as executive director of the Sláintecare programme office and Tom Keane to chair the Sláintecare Advisory Council are welcome developments. Both are politically savvy, but it remains to be seen if it was unwise of them to commit to their positions without the government plan published and a clear commitment to how much and how Sláintecare will be funded.
But perhaps there is some hope. Recent referendums on marriage equality and repealing the Eighth Amendment have shown that the public is way ahead of the politicians when it comes to an appetite for change and a more inclusive Ireland. Both had their origins in a citizens’ assembly. Perhaps the time has come for a citizens’ health assembly, where members of the public trash out the detail and priorities of Sláintecare, a forum where these complex issues would be openly and widely discussed in the media.
Politics is the art of the possible. Given the lack of leadership and vision on Sláintecare, maybe the people need to lead the politicians on health matters, to make them realise that Sláintecare is a very rare opportunity for reform, reform that needs to begin now, reform which our political leaders cannot afford to sabotage.
Sara Burke is a health policy analyst in the Centre for Health Policy and Management in Trinity College Dublin. She co-ordinates a research team which provided technical support for the Oireachtas Committee on the Future of Healthcare which produced the Sláintecare report