Professor Steve Thomas:

I thank the committee for the invitation to this meeting. We are delighted to be here. I am accompanied by Pathways team members Dr. Sara Burke and Dr. Bridget Johnston, whose assistance has been invaluable.

The committee asked us to evaluate the Sláintecare implementation strategy and present our work on re-phasing the original Sláintecare costings. This research was presented at the final seminar of the pathways to universal healthcare project, funded by the Health Research Board, HRB, which took place a week ago in Trinity College. It also draws on our experience of working with the Oireachtas Committee on the Future of Healthcare at the end of 2016 and early in 2017, when we had the privilege of working closely with some members of this committee.

The Sláintecare implementation strategy was published on 8 August 2018 and Ms Laura Magahy began as the executive director of the Sláintecare programme office in September 2018. The implementation strategy has four goals and ten interlocking high-level strategic actions, each of which have further specific actions. A brief critique of the Sláintecare implementation strategy follows, using the framework which structured the work of the Oireachtas Sláintecare report. We compare the treatment of vision, principles, entitlements, integrated care, funding and implementation in the Sláintecare implementation strategy with the Oireachtas Sláintecare report.

The Sláintecare implementation strategy refers regularly to the Sláintecare vision and restates the principles contained in the original report. The Sláintecare vision as specified in the Oireachtas report was for a universal health system accessible to all on the basis of need which is free at the point of delivery or at the lowest possible cost. The Oireachtas Sláintecare report defines what it means by universal healthcare and outlines the services that were to be included in the universal system. It specified that all residents would be entitled to these services and that this entitlement would be backed by legislation alongside a wait time guarantee. Everyone in Ireland would be entitled to a full package of services, free or at low cost, within a set period of time. It detailed the phasing and costings required to deliver such care. The Sláintecare implementation strategy is much more conservative, referring to eligibility rather than entitlement. Action six refers to expanding eligibility on a phased basis to move towards universal healthcare. It uses the term "universal eligibility" which is, at worst, an oxymoron and at best, only a conditional commitment. It goes on to state that the vision is that all citizens "will have universal access to healthcare, in both the acute and community settings.". These statements appear contradictory implying either a lack of understanding of the terms or a watering down of the commitment to universalism as laid out in the Oireachtas Sláintecare report.

The Sláintecare implementation strategy upholds the vision of integrated care as specified in the Oireachtas Sláintecare report. In particular, an imminent decision on the alignment of community services with hospitals groups as well as the allocation of resources through regional integrated care structures on the basis of population health need are both positive aspects of the implementation strategy.

Goal No. 3 of the Sláintecare implementation strategy is to ensure the health service is financially sustainable. It has a strong emphasis on productivity and achieving value for money. However, there is no recognition of household financial sustainability, little about eliminating or reducing charges and no national health fund as specified in the original report. There is a specific action to "design, establish and resource a multi-annual transition fund with appropriate governance to support the change process". While the capital aspects of the Oireachtas report transition fund are included in the national development plan in terms of community diagnostics, eHealth, primary care centres, new hospital capacity and elective-only hospitals, there is no mention of the funding required to train increased numbers of healthcare professionals for strong primary and community care service as detailed in the Oireachtas Sláintecare report. Neither is there any specification of the additional money required to fund the expansion of entitlements and to support the reform process as specified in the Oireachtas Sláintecare report.

The Pathways team has reworked the Oireachtas Sláintecare cost projections to provide another option for funding. This extends the implementation period to 12 years and elongates some of the phasing of specific components within that. We would be delighted to show members some slides of these after this opening statement.

Goal No. 1 of the Sláintecare implementation strategy is to "deliver improved governance and sustain reform through a focus on implementation". This puts implementation up front and centre, with a map of the Sláintecare implementation structure. However, the implementation strategy critically lacks the specifics of the original Sláintecare Oireachtas report in terms of targets, phasing, timelines, milestones and the budget needed to deliver it. It is important not to reinvent the wheel.

In conclusion, the publication of the Sláintecare implementation strategy, the appointment of Laura Magahy and the establishment of the Sláintecare programme office are all necessary and important developments. The Sláintecare implementation strategy begins to do the important task of weaving together reforms that were happening anyway with the Sláintecare reforms. However, there is a need to keep an eye on the Sláintecare Oireachtas vision and ambition and the essential components of entitlement and funding which are lacking in the implementation strategy. Nevertheless, the strategy progresses the Oireachtas Sláintecare report by integrating clinical and corporate governance. The emphasis on public engagement on health and well-being, a workforce engagement plan and the development of a citizen care master plan are welcome additions and may well be critical to triggering the political commitment and leadership that is needed to fund and deliver the vision as laid out in the Oireachtas Sláintecare report.

We look forward to further discussions with the committee on this.