Put simply, Sláintecare is the name for the initiative that aims to reform how healthcare is provided in Ireland, moving away from a two-tier system - split between public and private -and towards a system based on medical need.

“Our task has been to consider how best to ensure that, in future, everyone has access to an affordable, universal, single-tier healthcare system, in which patients are treated promptly on the basis of need, rather than ability to pay,” Shortall said in 2017.

At its core, Sláintecare aims to tackle the main problems faced by healthcare in Ireland, including patient care, waiting lists, high costs, over-reliance on hospitals, and lack of adequate community care. It also seeks to improve eHealth (electronic health) and access to healthcare in general.

Sláintecare, as originally envisaged, also seeks to move away from the national body of the HSE and instead establish six Regional Health Areas (RHAs) across Ireland, with each one responsible for its own budget and care delivery.

To do all this requires a significant system change in how Irish healthcare operates.

Following the publication of the Sláintecare report, opposition politicians were critical of the slow progress in moving forward its recommendations.

In August 2018, the then-government published the Sláintecare Implementation Strategy (SIS), which set out a 10-year framework for the implementation of key reforms to the healthcare system.

The Sláintecare Programme Office (SPO) was set up to oversee this implementation and the Sláintecare Implementation Advisory Council (SIAC) was set up to advise the SPO.

A number of high profile figures were appointed to the SIAC. It was chaired by Dr Tom Keane, a notable leader in the field of cancer research who led the overhaul of Ireland’s cancer services between 2007 and 2010.

Laura Magahy - a design and project consultant who has been involved in a number of significant public sector projects over the past 30 years - was appointed as the executive director.

Speaking to The Journal in 2022, Dr Sara Burke, assistant professor in the Centre for Health Policy and Management at Trinity College Dublin (TCD), who has worked extensively on Sláintecare research, said that initial progress of reforms was slow, but implementation began to ramp up in late 2019 and early 2020.

“By the end of 2019/early 2020, we were beginning to see momentum,” said Burke.

For example there were one thousand extra staff flagged [for Sláintecare] in Budget 2020, which was announced in October 2019. That was the first time there was anything like the investment as originally envisaged in the 2017 report being delivered on.

In its progress report for the implementation of Sláintecare in 2019, the Department of Health said that 138 projects had been progressed, with 112 of them on track, 24 facing minor challenges, and two facing significant challenges.

Overall, Burke said that the investment or the staff weren’t made available to fully implement Sláintecare, but that before the pandemic, things were improving.

“Then the pandemic happened and obviously everything was deflected onto Covid. Everybody had all hands on deck for a once-in-a-century pandemic and that was quite understandable,” she said.

Covid saw the Irish healthcare system - and all of Irish society - switch into emergency mode, as the nation faced unprecedented challenges.

While the system was put under immense strain, and waiting lists (which were already high) skyrocketed, a number of positive initiatives were put in place.

“I think one of the things that happened with Covid was that the system was given money and freedom to innovate, and because there was this big push to keep hospitals free for Covid surges, lots of innovation has occurred across the system,” said Burke.

What we saw during Covid was the health system under huge pressure, but actually coping pretty well and also loads of innovation and change on the ground.

“So I think our Covid response has shown us that we can do huge health system change very quickly.”

Budget 2021 saw a significant increase in health spending, as the government poured money into fighting Covid. Of the €4 billion extra in health funding, €1.35 billion was dedicated to implementing Sláintecare initiatives.

Budget 2024, however, saw €22.5 billion being set aside for health services, just €1 billion more than the previous year, despite added inflationary pressures. Of this amount, just €100 million was dedicated to new measures, leading to criticism from the major medical representative organisations.

As well as this, Sláintecare wasn't mentioned as part of Budget speeches by any Government minister.

"Sláintecare was presented as a genuine, all-party attempt to renew and reform healthcare in Ireland," Independent TD Matt Shanahan said in the Dáil at the time.

Yet, even before the pandemic, it looked as though it had been dumped in favour of projects: trophy projects, grandiose projects and the most delusional blue sky projects.

Shanahan's criticism echoed that of former members of the Sláintecare Implementation Advisory Council (SIAC) board, who resigned in 2021.

In May 2021, the Government published its Sláintecare Implementation Strategy & Action Plan 2021-2023, which included details on 11 significant projects to increase capacity in the community, to address waiting lists, to provide management of chronic diseases outside hospitals, to empower patients, and to innovate in the area of eHealth, among others - all key areas of Sláintecare.

In her forward to the strategy, executive director Laura Magahy said that “steady progress has been made in implementing key reforms”.

With the goodwill, funding, and implementation focus that has been built up for Sláintecare, collectively we have the opportunity over the next three years to implement Sláintecare at pace and continue to translate the Sláintecare Report from shared vision to reality.

Just four months later, however, Laura Magahy resigned her position as executive director of SIAC. In her resignation letter, she cited slow progress in three key areas of the Sláintecare reform: the regional health areas; eHealth, and waiting lists.

Soon after, Dr Tom Keane - the chair - also stepped down, stating that “the requirements for implementing this unprecedented programme for change are seriously lacking".

Later that month, gastroenterologist Professor Anthony O’Connor also stepped down from SIAC.

In his resignation letter, O’Connor said that “fundamental failures of governance, accountability and commitment continue to make any chance of success impossible”.

“It is now clear to me that the culture of collaboration, respect, community and engagement that had been envisaged by the Sláintecare report has been bulldozed.

“What has been chosen by Government to replace it is entirely incongruous with the principles of the project.”

Following these resignations, SIAC was disbanded by Health Minister Stephen Donnelly in October 2021, with a new Programme Board established to oversee the implementation of Sláintecare projects.

This Programme Board is co-chaired by the Secretary-General of the Department of Health Robert Watt and the CEO of the HSE Paul Reid.

Despite being rarely mentioned by Stephen Donnelly in the Dáil, the Government published its Sláintecare Progress Report 2022 and Action Plan 2023 at the end of March last year.

The report found progress had been made in a number of key areas. These included approval to split the HSE into six health regions, which was implemented in March 2024. However, these new RHAs do now have their own boards and are ultimately answerable to the HSE.

As well as this, the report highlighted progress with the public-only consultant contract. In November, it was reported that more than 1,000 consultants had signed up to the contract, which is aimed at improving services and access in the public health sector.

However, consultant and non-consultant hospital doctors expressed strong opposition to the new contract when it came into force in 2013, with members of the Irish Medical Organisation (IMO) voting to reject it at the time.

The report also raised concerns at the number of doctors soon to be reaching retirement age:

Currently 22% of doctors, 27% of dentists, 22.5% of pharmacists are aged over 55 and will be approaching retirement, on average, in the next 10 years.

To address this issue, the report states that the Government needs to "significantly increase the number of training places available to Irish and EU students" in order to increase the supply of doctors and nurses.

The progress report also highlights the continued challenges in reducing waiting lists, one of the central issues with Ireland's health service. While it found that in 2022 the overall number of patients exceeding the Sláintecare maximum wait time targets fell by 11%, the report also highlighted continued issues.

"The Government recognises that acute hospital scheduled care waiting lists are far too long, and that many patients are waiting an unacceptably long time for care," the report states.

However, it said that the "unacceptable trend has now been halted and waiting lists and waiting times are now decreasing as a result of the interventions funded by our annual action plans".

While health experts have stated that Sláintecare reform is progressing at a slow pace, the government has been accused on a number of occasions of “cherry picking” certain reforms and disregarding others.

“The original report is hugely transformational of the whole system, it's a big project. I often describe it to students when I’m teaching, as if you look inside a clock and you think of all the cogs and pieces that have to turn together to make a clock tick - I think it's a useful way to think about health systems,” said Burke in 2022.

"So for example hospital waiting lists - the biggest delay in accessing care is that delay with an outpatient specialist… You can wait months or often years before you get to see that specialist.

“In order to fix that problem we need more specialists in the hospital, but we also need many more, say, nurses and physios and occupational therapists working in the community.

“Because if we have them working well in teams at a community level, then lots of people won't have to end up going to see that specialist in the hospital if they get that early intervention and care.

So there are lots of different wheels that need to turn to fix the system rather than just: we need more doctors in that hospital. And that's the whole system bit. And that's the problem with cherry picking.

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