Dr. Sara Burke:

Good morning. I thank the Chair and committee for inviting us to appear before the committee to discuss Sláintecare's implementation. The chair has introduced us already. One reason I am here is that I lead on a project funded by the Health Research Board, which is harnessing the lessons from the Covid-19 health system response to inform Sláintecare. With me is Dr. Bridget Johnston, who is leading her own research project on palliative care. She led on an aspect of Foundations, which was reviewing the international evidence on population-based resource allocation policy, which is particularly relevant to the roll-out of Sláintecare in the regions. Professor Steve Thomas, is the Edward Kennedy chair of health policy in Trinity and a Health Research Board research leader with his RESTORE project, which is evaluating international health system reform and resilience, which is also really relevant today. The three of us had the privilege of being part of the Committee on the Future of Healthcare, chaired by Deputy Róisín Shortall, which produced the Sláintecare report.

Sláintecare is a ten-year plan for health reform which outlined a high-level road map to deliver universal, timely access to quality, integrated health and social care in Ireland. In July 2019, the Oireachtas report on Sláintecare was adopted by Government in the form of the Sláintecare implementation strategy. Laura Magahy was appointed Sláintecare executive director, heading up the Sláintecare programme implementation office in the Department of Health in September 2018. The first annual action plan was published by Laura Magahy and her team in February 2019. While there are differences in emphasis in the reports, in its essence, Sláintecare is quite simple. It is about how everyone in Ireland can get timely access to the right care, in the right place, at the right time. Achieving this plan was underpinned by delivering much more and better public health so that everyone is supported to live healthier lives, a universal entitlement to the public health system with much greater provision of care outside of hospital, and the delivery of quality, integrated care at the lowest level of complexity.

Other important components include the removal of barriers to care such as charges, waiting times - a key component was the reduction of waiting times - supporting the workforce and building up the capacity of the public health system to deliver this care, including the removal of private practice from public hospitals. These actions, as well as strong implementation measures, will ensure the system is accountable and transparent and, critically, that it strives to meet the needs of everyone but particularly those who need it most.

Early progress on Sláintecare has been slow. The Government was slow to adopt the report and then slow to act on it. One of its first actions was to bring the Sláintecare office into the Department of Health contrary to the original Oireachtas report's recommendation for it to be in the Department of An Taoiseach.

Up to early 2020 and Covid-19, there was not the financial resource allocation or political priority needed to implement extensive reform such as Sláintecare. This was evident in the failure to match free care commitments in the original report. That said, in the months approaching the start of Covid, momentum was building around Sláintecare. That was evident from joint work between the Department and the HSE on the regions, the beginnings of good community and stakeholder engagement, the establishment of the Sláintecare integration fund and the publication of the de Buitléir report, which endorsed the removal of private practice from public hospitals.

When the pandemic arrived, pretty much everyone involved in Sláintecare was redeployed to the Covid-19 health system response. It quickly became apparent that Covid-19 was not a short-term crisis. People began to realise that many of the most appropriate Covid-19 health system responses were closely aligned to Sláintecare, including a big push on prevention in public health, keeping people out of hospital, significant extra investment to build up the health system’s capacity and the roll-out of all Covid-related services as universal, free at the point of delivery, with access based solely on medical or health need. Furthermore, there was a fresh realisation of the high value of a well-functioning health system to the economy and broader society.

Key publications during Covid include the 2020 programme for Government, the HSE corporate plan and the 2021 Sláintecare implementation strategy and action plan. These showed much stronger alignment between the different parts of the system with the Government, the Department of Health and the HSE operating in tandem with the aim of delivering on Sláintecare. This combined with significant additional resource allocation during Covid to health allowed the system to boost its capacity with there now being an extra 18,000 whole-time equivalent HSE funded staff as well as many more hospital beds, and community investment. These have all helped to advance Sláintecare.

Research led by Dr. Sarah Parker shows an agile health system response during Covid with those in leadership and on the front line freed up to provide universal access to integrated care during the crisis. The research found that this was nurtured through the whole system having clear, common and shared goals and information, as well as harnessing, sharing and supporting innovation. The research also found that trust and relationships were key to providing better and more accessible care during the pandemic. Finally, the research found that the system is at significant risk of reverting to type now and not holding on to the positive impacts of the pandemic.

Other research led by our colleague, Dr. Padraic Fleming shows that while there are significantly many more staff in the health system, we are still continuing to make the mistakes of the past and putting those staff in acute hospitals. We need many more staff in hospitals but, ultimately, for Sláintecare to succeed we need many more staff in primary, community and social care settings.

While our research has found positives during the Covid response, there are negative impacts of the pandemic, which is most evident in longer waiting times to access care and a demoralised and tired workforce. Another paper we jointly published in The Lancet Regional Health in 2021 concluded that Covid boosted Sláintecare’s implementation and had the possibility to transform the Irish health system. However, within days of The Lancetpublication, Sláintecare’s lead, Ms Laura Magahy, resigned citing slow progress in three key areas requiring dedicated, focused reform, which are regional health areas, RHAs, ehealth or digital health and waiting lists. Upon her resignation, Ms Magahy specified that these reforms required a governance and oversight structure other than that which existed, in particular in light of the substantial additional funding being allocated towards the reform of the health services. Professor Tom Keane, chair of the advisory council also resigned. What followed the resignations was the dissolution of the Sláintecare programme implementation office and the Sláintecare implementation advisory council with the Minister for Health, Deputy Donnelly, appointing Mr. Robert Watt and Mr. Paul Reid as co-chairs of the newly-established Sláintecare programme board. There were various appearances by the co-chairs in front of this committee, in 2022 as well as by the acting CEO, Mr. Stephen Mulvany at the previous meeting of this committee. Last year also saw the publication of the business case for the regions, the Sláintecare progress report for 2021 that was published in April, and the 2022 Sláintecare action plan that was published in June. Of note, no Sláintecare progress reports have been published since December 2021.

On the plus side, last October’s budget detailed health measures that are very much aligned with Sláintecare, for example, the abolition of hospital fees. which were originally earmarked for year 1 of Sláintecare; more significant budget allocation to health and plans to extend free GP care to 500,000 people based on low income. These measures are all significant for people in the midst of a cost-of-living crisis. Last December, the Government announced its approval of a public-only consultant contract and the next steps for the development of two elective-only hospitals with the Minister, Deputy Donnelly, retaining the health brief despite a Government reshuffle. What we can see was another loss of momentum after the Sláintecare resignations but greater momentum built again in 2022, and this happening alongside most new services being universal and free at the point of delivery.

Work we are currently conducting on the implementation of the regions is finding a changing governance architecture and an absence of clarity on roles and responsibilities, leading us to question if we have ever had the right governance architecture for Sláintecare. A key question for this committee, which monitors Sláintecare's implementation, is: what is the optimum governance structure for Sláintecare? This research is also finding that the RHA design is a top-down process and it is not inclusive of key stakeholders such as GPs, voluntary organisations and citizens. That makes us question the type and quality of engagement and participation in the reform process as well as conflicting policy directions. The committee has significantly argued those here and one such example is the regions, an issue to which we can return. There are also persistent delays. For example, the RHA implementation plan was due to be published last year and remains unpublished. There is no HSE national service plan yet, even though today is 1 March 2023 and there is no Sláintecare action plan for 2023. That said, progress is happening in the context of significant extra Sláintecare health budget allocation, and political priority in the form of strong ministerial support for universal healthcare and most services being introduced as universal and free at the point of delivery.

In conclusion, in terms of Sláintecare implementation we have a mixed score card. Each change that happens is welcome but not enough when situated within the bigger picture of whole-system reform. An example of this is the current Government commitment to give GP visit cards to all households whose income is €46,000 or less from April. The original report envisaged the roll-out of universal primary care not just GP care, and that primary care would happen in tandem with GP care. That would allow care to be provided at the lowest level of complexity and cost, and not overwhelm GPs. It will be hard or impossible to realise Sláintecare with piecemeal reform. What is needed is whole-system reform and recognition that we are only now at the starting point of proper implementation. Delivering Sláintecare in full will require years more of high political priority, resource allocation and skilled leadership, as well as meaningful and consistent engagement with all stakeholders, including citizens and those on the front line. We look forward to questions and discussion. I thank members for their attention.