Give me a crash course in ... the Sláintecare debacle

Stephen Donnelly immersed in first full-blown non-Covid health controversy

What is Sláintecare when it’s at home?

The best way to think about Sláintecare is as an attempt to fix long-standing problems in the health service by breaking it out of the relentless short-termism that has dominated health policy-making in Ireland. The idea was to move health, in broad terms, away from the policy priorities and political agendas of different governments. The overarching goal is to deconstruct the "two-tier" structure of health provision, with access determined by need, not ability to pay.

How was this done?

In 2016, an all-party committee on the future of healthcare was set up. Chaired by Social Democrats co-leader Roísín Shortall, it published its final report in May of the following year. The next step was figuring out how to get the plan off the page, and into action. Laura Magahy, a business figure who previously oversaw the regeneration of Temple Bar and the development of the Digital Hub, was appointed as the executive director of the Sláintecare Programme Implementation Office. She was appointed as a deputy secretary in the Department of Health. This is a senior role – the same rung of the civil service ladder as Chief Medical Officer Tony Holohan. A Sláintecare Implementation Advisory Council of 21 people was also appointed, chaired by Prof Tom Keane, an Irish-born but Canada-based oncologist who worked as director of the National Cancer Control Programme previously.


So what’s gone wrong?

Last month, both Magahy and Keane resigned from their roles. In his resignation letter, Keane wrote that: “Sadly, I have come to conclude that the requirements for implementing this unprecedented programme for change are seriously lacking.” In her resignation letter, Magahy said good progress had been made in many important areas, but that “progress had been slow in three key areas requiring dedicated, focused, reform effort: regional health areas; eHealth, and waiting list. These are the areas on which substantial reform depends. It is my view that these reforms require a governance and oversight structure other than that which exists at present, in particular in light of the substantial additional funding being allocated towards the reform of the health services”.

More resignations from the advisory group have followed, despite talks between the HSE, Minister for Health Stephen Donnelly and the group in the interim. Prof Anthony O’Connor, in his resignation letter, said there was a “destructive” and “contemptuous” management of the process which led to the original culture of Sláintecare being “bulldozed”. He said the plan was now “doomed to fail”, and a key part of it, the devolution of centralised healthcare function, “will not happen”.

Why precisely has this happened?

It's not quite clear; for all the strong words that have issued during resignations. There was little light shed on the reasons at the Oireachtas health committee this week, with top civil servant Robert Watt insisting there had been no disagreements on key issues like regionalisation, which he said hadn't been yet decided on. He suggested there were some differences over the pace of change, and that he had not favoured moving ahead during the pandemic due to competing pressures on the health service.

Donnelly said he wasn’t aware of the frustrations before the resignations, but later in the committee session said Magahy had discussed her general frustrations with him. He also seemingly contradicted Watt, who said it was “nonsense” to suggest there was institutionalised resistance to change, when saying “of course” there would be resistance to major change.

So what happens next?

Donnelly has delegated management of the process to a new board, co-chaired by Watt and HSE chief executive Paul Reid. In addition to putting his political stamp on the process – and making him more directly politically responsible for its successes or failures – this has led to charges from the Opposition that Donnelly’s new process is lacking in transparency and has severe governance weaknesses. Shortall termed it a “hostile takeover” of the Sláintecare programme.

The next set-piece is when (and if) Keane and Magahy accept standing invitations from the committee to appear before it. October 20th has been pencilled in as a possible date. It seems that Donnelly is now immersed in his first full-blown non-Covid healthcare rolling controversy.