Just a month in office as health minister and Leo Varadkar has confirmed that three of the government's top priority health promises will not be realised.
The HSE will not be abolished next year, every citizen will not have free GP care by 2016, while universal health insurance will not be in place by 2019.
The decision to abolish the HSE was a populist pre-election tactic deployed by Fine Gael in the run up the last election. The Programme for Government said it 'would cease to exist', the subsequent government roadmap on health reform 'Future Health' said 'the HSE would be dissolved' in 2015.
All this was harebrained political rhetoric without an ounce of clarity as to what would happen the 97,000 thousand staff who provide care day in day out to millions of Irish people.
Have we not learnt from the HSE formation and its subsequent constant reorganisation that restructuring alone does not solve the problems in the health system? Varadkar's call to keep the HSE in place until the establishment of hospital groups and the introduction of new payment mechanisms have bedded down makes sense and provides much needed stability for the HSE. Although some involved in the hospital groups' formation say their existence and governance also require a re-examination.
The government is sticking to its commitment of universal free GP care but pushing out the timeframe beyond the original deadline of 2016. It is likely that just children and over 70 years olds will have access to GP care without fees before the next election. Critically, the new minister is selling it as a key stepping stone to universal health care. In all his media outings as the new health minister, Varadkar has said he believes Ireland should have universal health care, just as all other European countries do.
This change of language from universal health insurance to universal health care is really significant. Interestingly, Varadkar is also talking about universal primary care rather than just universal free GP care. This will include the management of chronic diseases in the community, minor surgery, dental and optical services. It will be interesting to hear more detail on the new minister's vision and timescales for universal primary care.
In the last week, Varadkar has put the final nail in the coffin of James Reilly's version of universal health insurance. Initially, it was meant to be legislated for by 2016 with full implementation during a second term in office. The recent White Paper promised universal health insurance by 2019 and in Tuesday's Irish Independent, the new minister admitted that this was too ambitious. And he is dead right.
James Reilly based his plan on the Dutch model delivered by competing private health insurers. This took over a decade to introduce in Holland and, eight years into it, they are still tweaking it and it is proving incredibly expensive. The new minister has said he sees universal health insurance as the third stage to universal health care, but kicking to touch on the deadline buys him time to manoeuvre or even bury Reilly's plan, which had little if any public or political support.
Varadkar has also revealed a more nuanced approach to the controversial issue of delivering medical cards on the basis of medical need. In his first week as health minister, he said he thought it would be very difficult "to create a hierarchy of illnesses", undermining the shift in policy made by the cabinet of which was a member just weeks previously. In contrast, during an RTE radio interview earlier this week, he conceded that even though he is a GP and a politician, he did not really understand medical cards and that he should wait and see what the expert group set up to make recommendations on this matter has to say. Someone must have given him a good talking to on this matter.
Varadkar has got off to a very strong start in this notorious ministry. He has obviously set himself a few priorities including securing a 'realistic' budget for health; delivering on universal primary care as a stepping stone to universal health care, improving staff morale, bringing down the costs of drugs and private health insurance.
In many way, Minister Varadkar is doing exactly the opposite what James Reilly did - he is taking time to get it right, not rushing enormous change through for the sake of it. He has explicitly stated he wants to 'steady the ship', he's talking to people, getting on top of his brief, and not even shafting his predecessor along the way.
He's been out there giving clear, calm messages about health system reform. If anyone is able for what he himself described as "the fiscal hawks" in the departments of Finance and Public Expenditure and Reform, it is Varadkar.
How he copes with medical cards and manages the Budget 2015 negotiations in the months ahead will be the first real tests for this nimble health minister who has got off to an impressive, capable start.
Sara Burke is a health policy analyst and research fellow in Trinity College @sburx