In February, Jennifer Carroll MacNeill became the latest Minister for Health to announce a new initiative to reduce the amount of time patients have to wait for treatment in public hospitals.
The Irish health system has been struggling for years to deal with growing waiting lists with bed and staffing capacity lagging behind demand. The answer for successive governments has been to either use the private sector or to get existing personnel to do more in their own time, while the Health Service Executive moved to increase its own resources.
The amount of money allocated to these initiatives has been staggering.
The Minister’s plan in February involved a €420 million investment, including €190 million for the HSE and €230 million for the National Treatment Purchase Fund (NTPF) – the organisation established by Micheál Martin 20 years ago to buy treatment for public patients.
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Between 2022 and 2024 under Stephen Donnelly, about €1.23 billion was allocated to the HSE and the NTPF.
Government funding was essentially spent in three ways. First, it allowed the HSE to appoint more staff to increase its own capacity. Second, it allowed the NTPF to buy care in private facilities. Third, it allowed for what is known as “insourcing”, where health service personnel are paid by the NTPF or other entities to provide treatment outside normal hours in public hospitals for those on waiting lists.
A recent internal report carried out by children’s healthcare group CHI, has led to more intense scrutiny of the various waiting list initiatives. The report alleged that a doctor had delayed operations on children before eventually they were treated at weekend clinics that he was operating separately.
In the Dáil, the Taoiseach said the CHI report “makes for shocking reading of the most profound kind, which not just goes to the heart of the misuse of NTPF funding but more seriously raises fundamental concerns at that time about safety for children receiving surgery”.
Cian O’Callaghan of the Social Democrats told the Dáil that the report found the consultant earned more than €35,000 by keeping very young children on a waiting list for years. “They were eventually treated using the NTPF when they were transferred to the consultant’s weekend clinic, but they could have been treated by other doctors years earlier. When all of this was discovered, it was kept a secret and the consultant was allowed to retire and sail into the sunset.”
The Minister and HSE chief Bernard Gloster had been kept in the dark about the report but were given copies last week.
There have been other controversies surrounding waiting list funding.
On April 18th, Mr Gloster directed his senior leadership team to halt, for the present at least, aspects of the “insourcing” arrangements. He commissioned a survey to establish the dependency of the health system on such practices and to ensure “there were no unintended consequences”.
Mr Gloster suspended insourcing where staff were “engaged, hired or paid” by separate entities on initiatives in their area of work.
Insourcing was only permitted in cases where the HSE directly engaged its own staff through payroll.
His instructions followed discussions with Ms Carroll MacNeill and followed an internal audit report, details of which were revealed in The Irish Times last September.
The HSE internal audit found two companies which received more than €1.5 million between them in contracts awarded by University Hospital Limerick without a competitive procurement process were owned or part-owned by employees at the facility.
A third company, which received a contract of nearly €400,000, had a HSE employee at a different hospital as a director.
Auditors stated €14.2 million was paid out to third-party providers by University Hospital Limerick in 2023 under the Government waiting list initiative without an open procurement process.
Auditors said there was no evidence of the HSE employees being involved in the awarding of the contracts.
In May, Aontú leader Peadar Tóibín told the Dáil in one case a consultant created a firm to read scans and “used the hospital public waiting lists to then funnel work through rostering into his own private company”.
The NTPF said it was deeply concerned at the CHI internal report. It said it had never received any complaints about hospitals or doctors.
Last year, the fund paid €155 million to private hospitals and about €80 million to public facilities.
It seeks private hospitals to tender for packages of care and it then attempts to match this capacity with those waiting longest in public facilities.
Sara Burke, associate professor of health policy at Trinity College, said the NTPF and the various waiting list initiatives were initially established more than 20 years ago as temporary measures while the State built up its own public capacity. They had, however, become permanent, integral parts of the system, she said.
“Given the amounts of money now being allocated, there is a need to look at how transparent the arrangements are and the governance of these schemes,” she said.
The Opposition is now calling for reforms.
David Cullinane of Sinn Féin said there were concerns about potential conflicts of interest and called for a centralised system which would see patients referred to a hospital rather than an individual consultant.
“We have to ask genuine questions about what work some consultants are doing from Monday to Friday to carry out public procedures. We need to contrast that with the so-called blitzes and private clinics they are organising and running, while charging €200 for each client they see and making very handsome amounts of money.”
Marie Sherlock of the Labour Party said she was uncomfortable about how the current arrangements had grown, the dependency on it that had developed and “the ability of the public system to wean itself off it”.
Mr Tóibín questioned the safeguards in place against conflicts of interest. “Last year 80,000 public patients were treated in private hospitals at a cost of €100 million. The majority of these treatments should have been done in the public system.”
Ms Carroll MacNeill told the Dáil she would be taking further steps to remove the anomalies, which she said existed “because of the overhanging mix of public and private activity”.
