One of the few positive aspects of the recent controversy over Sláintecare, is that it has placed a big spotlight on the promised health reforms.

During the pandemic, Sláintecare barely got a mention. The recent spate of high-profile resignations, political reaction and this week's Oireachtas hearing with the Minister for Health and his Secretary General, have turned up the dial on the biggest health reforms planned for Ireland. The focus is on it like never before.

So, in an odd way, the Sláintecare drama of recent weeks may end up helping to clear obstacles from the reform path.

The 10-year plan is supposed to deliver a single-tier health system. An end to private practice in public hospitals. Free GP and hospital care, plus more community and GP-based services. The price tag is €2.8 billion, with a once-off capital spend of €3 billion.

To understand the ongoing controversy, we need to understand why some of the top executives resigned.

When Professor Tom Keane (Chairperson of the Sláintecare Implementation Advisory Council) and Laura Magahy (full-time Executive Director of the reform programme) quit, I put in a Freedom of Information (FoI) request to the Department of Health, for all correspondence in the period leading up to their resignations.

Much of the detail of those resignation letters I have outlined in a previous article here and reported on.

Professor Tom Keane and Laura Magahy

At the end of this week, I received a reply to my FoI to the Department of Health. Of 13 documents discovered for the period in question, three were released to me, in part. Ten emails from Ms Magahy to the Secretary General, Robert Watt, were not released to me. The dates for these emails are important, as they are from 1 October to 7 October, just before Ms Magahy quit.

The reason why these emails were not released to me was because the Department of Health said that under Section 29 (1) of the FoI Act, they related to a deliberative process.

The three letters released to me were the letter of resignation from Prof Keane to the Sláintecare Implementation Advisory Committee of 6 September. The Laura Magahy letter of resignation to the Minister for Health of 7 September. Plus, the Laura Magahy letter of resignation to the Department of Health management board of 8 September, which has not been published up to now.

In his letter, Prof Keane said that while the Covid pandemic undoubtedly made the project more difficult, he believed that "fundamental failures of governance, accountability and commitment continue to make any chance of success impossible".

At the Oireachtas Committee on Health this week, Minister for Health Stephen Donnelly said he was puzzled by Prof Keane's view. The minister pointed to the situation where a recent review showed progress on the reforms with 97% on target or affected by small delays.

In her letter of resignation to the Department of Health management board, of 8 September which I obtained under FoI, Ms Magahy says: "I also understand that the HSE wishes to defer implementation of the Regional Health Areas, but it is my considered view that reform cannot happen without devolution of budgets on a population health basis, and clinical oversight on a regional basis, with supporting eHealth solutions."

She continues: "As we have discussed on several occasions, implementing these reforms requires 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 service."

The pause on establishing the six planned Regional Health Areas was at the request of Health Service Executive CEO Paul Reid, due to the pandemic.

Both Minister Donnelly and Robert Watt, Secretary General at the Department, supported the delays in establishing the RHAs. Prof Keane and Ms Magahy wanted them to be in place in a two-year timeline. This appears to have been a big clashing point.

Robert Watt

In her resignation letter to the Department management team, Ms Magahy points out that Regional Health Areas (along with waiting lists and eHealth) are the areas "on which substantial reform depends".

At the Oireachtas Committee on Health this week, we heard that a plan and timelines for the RHAs has yet to be devised and presented to the minister. The expectation is that the RHAs may begin to be put in place from 2023. The concern the minister and Mr Watt had about doing this reform in a pandemic was the risk it posed.

The RHAs involve major functional change for the HSE. They will see the merger of community and acute care in each of the six areas. There is discussion as to what areas should stay at the centre of the HSE and what areas should be devolved. In all of these things there is power play.

The concern about doing the RHA change in the pandemic was that such major change could affect the delivery of services, which must go on during any reform. One of the other issues is that during any major administrative reform, some senior staff may be distracted by a battle to keep their positions, or to securing even higher ones, that may be created in the new structures.

Some of the harshest criticism at the committee hearing came from Róisín Shortall, who chaired the original all-party Sláintecare Report in 2017. She said the original report did not want the Sláintecare Reform Office based in the Department of Health amid fears the department would "capture" the programme there. She said that if the department was capable of reform, it would have happened now.

Social Democrat co-leader Róisín Shortall

Deputy Shortall claimed there was now a "hostile takeover over" of Sláintecare, that the department wanted to "suffocate" it and "embed" it in the building on Miesian Plaza in Baggot Street, Dublin. She also accused the minister and officials of going against the express wishes of the Dáil.

Both Minister Donnelly and Mr Watt vigorously rejected that suggestion and insisted that the department is up for change. In a memorable moment at the committee, Mr Watt suggested that too many people were watching episodes of 'Yes Minister' where resistance to change is the raison d'être of top civil servants.

Perhaps one of the most remarkable aspects of the controversy is how the Minister for Health was apparently kept in the dark about Ms Magahy's intention to quit. Had there been more time, might he have been able to persuade her to stay on?

Mr Watt had spoken to her a week before she quit and knew she was going to resign. He did not tell the minister but he did tell Human Resources. He told the committee this week that he wanted to respect her decision to speak to the minister herself. Mr Watt did not appear surprised by her decision to quit.

Ms Magahy was brought in to head the Sláintecare Programme as a full-time executive. She was placed at deputy Secretary General rank. The Sláintecare Report called for the head of this programme to be placed at Secretary General rank, so as to have access to the Taoiseach and equal access footing with other Secretary Generals and Departments. It never happened.

"The history of new hospital builds in Ireland is not a pretty one"

So, what is next? A small advisory group is being set up to look at the establishment of the planned six Regional Health Areas. The exact make-up of that body is not known yet.

A programme board is also being set up to be co-chaired by Mr Watt and Mr Reid. It will oversee the reform programme. The view has been taken that only top officials can really lead organisational reforms. With the establishment of the Programme Board, the term of office of the Sláintecare Implementation Advisory Council will expire on 24 October

Retiring members of the council wrote to the Taoiseach yesterday about the controversy. They warned that that the unexpected resignations of key people had caused concern that there are "fundamental obstacles" within the political and administrative systems, to successfully implement the reform plan. But they agreed that pausing the move to Regional Health Areas during the pandemic had been the right call.

On waiting lists, which is also a big part of Sláintecare, a new plan for 2022 with extra funding is expected in next week's Budget. An initial plan, for September to December, to deal with the impact of the pandemic and the cyber attack was published on Thursday.

There are also plans to build three new elective-only hospitals in Dublin, Cork and Galway, to help cut waiting lists. However, these hospitals will be day care facilities only, with no inpatient or overnight beds, so the type of care provided will not be overly complex requiring a stay.

The history of new hospital builds in Ireland is not a pretty one - many have been mired in long delays, cost-overruns and arguments about the best locations.

Ending private medical practice in public hospitals is a big element of the Sláintecare plan. This week, Mr Watt said that the timeframe for concluding the talks with consultants on a public-only contract was the end of this month.

Sláintecare is the only game in town. And the stakes are high. It will define how healthcare in Ireland will be delivered in the decades to come. The political task is to not only deliver on the promises but the deadline for reforms too. We have witnessed something approaching a 'High Noon' moment in recent weeks, with a few casualties.

However, all the recent drama may help contribute to a positive outcome. Time will tell. In the end, the only winners must be the patients.