In a presentation to a conference on the future of healthcare a couple of years ago, an anaesthetist from Cork urged that \u201cinnovative thinking\u201d was needed to tackle the perennial problem of patients waiting long periods for hospital treatment.<\/p>\n
This involved \u201cthinking up something new or to think about something old in a new way\u201d.<\/p>\n
Ken Walsh told the Health Summit conference that in the regular health system there were roadblocks to progress on dealing with the waiting list, such as staff availability, sick leave, absenteeism, pay and funding issues, as well as restrictions under the European Working Time directive.<\/p>\n
However, he suggested there was an alternative that would incentivise staff to work additional hours within the limits of European employment laws.<\/p>\n
The overall concept was relatively straightforward. With a growing and ageing population, demand for care was likely to surge and the ability of the public system to cope was limited. The State had been outsourcing patients on long waiting lists to private hospitals for years.<\/p>\n
But what about spare capacity in public hospitals? These had highly trained staff and expensive equipment, largely funded by the exchequer. But routine or non-urgent care was primarily a Monday-Friday, regular working hours operation.<\/p>\n
Unlocking unused capacity at night-time and weekends could allow tens of thousands more patients to be treated.<\/p>\n
Hospitals already offered regular overtime to staff. But this new \u201cthird party\u201d insourcing would mean private companies putting together teams of doctors and staff who would be paid premium rates to work in their public hospitals, outside of core hours. <\/p>\n
This \u201cthird party insourcing\u201d may have proved effective in getting more patients treated but it was also highly lucrative for those involved. And behind the scenes, it generated strong concerns about potential conflicts of interest, perverse incentives and governance and oversight shortcomings.<\/p>\n
[\u00a0Waiting list initiative suspended at Naas after concerns consultants paid directlyOpens in new window<\/a>\u00a0]<\/p>\n Around teatime on Friday of last week, the Health Service Executive sent a report to an Oireachtas committee on how much such insourcing companies had been paid.<\/p>\n Over 27 months to March 2025 three had, between them, received more than \u20ac70 million. One, EHF 29 Limited, received \u20ac54.636 million. Official filings showed it was largely owned by two doctors, Ken Walsh and Clodagh Ryan.<\/p>\n Accounts for 2023 show that EHF 29 Limited had recorded an annual profit of \u20ac2.39 million.<\/p>\n The company declined to comment this week but its website sets out the scale of its operations. It had carried out more than 70 waiting list projects in 22 acute public hospitals. From a small start in 2020 it assisted in the provision of treatment for 5,500 patients in 2021, 46,000 in 2022 and approximately 79,000 in 2023.<\/p>\n Its accounts for 2023 say that the average monthly number of people employed, including directors, was 576. <\/p>\n Among projects on which it has worked are day case surgery at St James\u2019s in Dublin, vascular surgery at Cork University Hospital, plastic surgery in Galway, breast clinics in Galway and Letterkenny, endoscopies in Ennis, Limerick and Wexford, and a pathology initiative in Waterford. <\/p>\n It is understood as part of its operations, it recruits \u201csuitably qualified staff\u201d from the HSE. <\/p>\n Another company, Rosata Recruitment, received \u20ac10.3 million in the 27 months to March. <\/p>\n This company\u2019s accounts list Ronan Corrigan as director and its report for 2023 said it had a monthly average of 29 doctors employed. It reported profits close to \u20ac500,000 for that year.<\/p>\n The company says it has been \u201cproviding a wide range of insourced surgical\/outpatient\/diagnostic\/endoscopy waiting list initiatives since 2020\u2033.<\/p>\n The HSE said another firm, Totally Healthcare, received \u20ac5.9 million in the 27 months for insourcing projects. The company says it works with hospitals across the United Kingdom and Ireland. <\/p>\n Last year, it announced a 12-month insourcing contract for oral and maxillofacial outpatient and day surgery cases with HSE hospitals in the west of Ireland.<\/p>\n [\u00a0HSE paid one firm \u20ac54m over 27 months for services to tackle waiting lists in public hospitalsOpens in new window<\/a>\u00a0]<\/p>\n \u201cAll procedures will be delivered during weekends when hospital facilities are not otherwise in use\u201d, it said.<\/p>\n Sinn F\u00e9in health spokesman David Cullinane described the HSE funding report as \u201cstaggering\u201d and warned that insourcing presented risks. <\/p>\n However, it was official policy. And while supporters of the idea, such as Dr Walsh in Cork, may have had a vision, it could not have been implemented without political backing. <\/p>\n Governments for years had struggled with waiting lists. Taoiseach Miche\u00e1l Martin as minister for health 20 years ago <\/a>had established the National Treatment Purchase Fund <\/a>to buy care for those waiting longest.<\/p>\n But after the Covid-19 pandemic there were serious problems. In February 2022 the then minister for health Stephen Donnelly said months of disruption during the pandemic had left more than 730,000 queuing for treatment.<\/p>\n The year before, Donnelly had introduced a short-term plan from September to December, which, he said, had provided care to an additional 40,000 people.<\/p>\n After Covid, Donnelly now had more money at his disposal than any of his predecessors and he now effectively turbocharged the drive on waiting lists.<\/p>\n Initially, in 2022, he launched a \u20ac350 million plan, which became a permanent feature in subsequent years.<\/p>\n Overall, the sums involved in tackling waiting lists were vast. Over four years, about \u20ac1.6 billion was provided. Some of this allowed the HSE to directly hire more staff, more went to the National Treatment Purchase Fund to buy treatment in private hospitals. But significant amounts went on insourcing arrangements. <\/p>\n Although regular overtime continued, third-party insourcing became increasingly common.<\/p>\n The framework on which this worked was a dynamic purchasing system introduced by the HSE. <\/p>\n This allowed hospitals operating a non-recurring initiative to conduct a mini-competition open to providers on the dynamic purchasing system. <\/p>\n A multimillion-euro private industry was about to develop inside the country\u2019s public hospital system.<\/p>\n [\u00a0The Irish Times view on hospital waiting lists: Straining to stand stillOpens in new window<\/a>\u00a0]<\/p>\n There were concerns about insourcing from early on. But they were mainly behind the scenes. Officially, the initiatives were working, particularly in bringing down the length of time people had to wait. Donnelly told the Cabinet last November that since September 2021, there had been a 58.5 per cent reduction in the number of patients waiting over 12 months, equating to over 169,000 people.<\/p>\n But in the background, there were concerns.<\/p>\n In recent weeks, The Irish Times received documents which suggested that within Children\u2019s Health Ireland<\/a> (CHI), the group that runs children\u2019s hospitals in Dublin, there had been particular unease about insourcing. <\/p>\n CHI paid \u20ac5.66 million to EHF 29 between 2023 and March 2025. It ceased insourcing initiatives in June.<\/p>\n However, some in the health system maintain that concerns existed more widely and the documents represented attempts to rehabilitate the image of CHI in the wake of recent controversies.<\/p>\n But nonetheless, CHI seems to have pursued its concerns about insourcing, albeit in private, including a meeting with the Health Service Executive in June 2023.<\/p>\n Children\u2019s Health Ireland said in a statement that its board \u201craised concerns regarding the concept of insourcing and the potential conflict of interest for staff, with HSE colleagues on several occasions\u201d.<\/p>\n [\u00a0Almost \u20ac100m spent on companies that use HSE facilities and staff to cut waiting lists after hoursOpens in new window<\/a>\u00a0]<\/p>\n The HSE said that in 2023, a meeting was convened between it and Children\u2019s Health Ireland representatives, including members of the CHI board, to discuss the provision and use of insourcing.<\/p>\n \u201cCHI expressed concerns at the meeting, which were shared by the HSE. It was agreed that insourcing was necessary as a short-term measure to address waiting list backlogs,\u201d the HSE said in a statement.<\/p>\n Children\u2019s Health Ireland said it reiterated its concerns on foot of a HSE memorandum (on insourcing) issued in February 2024 but agreed to continue with the initiative \u201cin view of the challenges to patient waiting times and with HSE assurance\u201d.<\/p>\n The HSE did not say whether it had alerted its board or the Department of Health to the concerns raised by Children\u2019s Health Ireland. <\/p>\n However, within the HSE internal auditors began looking at insourcing arrangements in 2023 and early 2024. <\/p>\n In September 2024 The Irish Times reported auditors had found that two companies which received more than \u20ac1.5 million between them at University Hospital Limerick without a competitive procurement process were owned or part-owned by employees.<\/p>\n Over recent weeks more controversies emerged involving CHI, Beaumont Hospital and Naas in Kildare.<\/p>\n [\u00a0Beaumont Hospital has NTPF waiting list funding suspended Opens in new window<\/a>\u00a0]<\/p>\n