Anne O’Connor recently replaced Bernard Gloster as chief executive of the Health Service Executive and Robert Watt will shortly be replaced as secretary general at the Department of Health. Moving the deck chairs on the Titanic is an outdated metaphor, however. Health is no longer the Angola it once was.

We are about halfway through a 10-year programme of reform in a health system that enjoys unprecedented resources and acute deficits in capacity. This is the moment Minister for Health Jennifer Carroll MacNeill should take full responsibility. Her predecessors could complain about inheriting an insoluble mess; she cannot. Carroll MacNeill has momentum, and if it falters, it is her fault.

Gloster may have been an appointed official, but he was unquestionably the most successful health politician of his time. His relationship with the Minister was the nexus in the system. He was a master of the political game with a forensic focus on issues that mattered to them, and in particular on the issues that matter to Carroll MacNeill.

It is less clear if he successfully institutionalised change, or changed culture, in the HSE. The focus on numbers on trolleys – which the Minister shared – moved the dial politically. It also displaced inactivity from overcrowded emergency departments to elective activity elsewhere in hospitals. Less visible, and harder to count, are elective cancellations – and many are urgent. When elective procedures are not even scheduled, they cannot be counted at all. There has been real progress in health. But there is also a presentational game of smoke and........

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