Promote a Culture of Performance Management in the Irish Health Service

“The launch of Akeso in Ireland marks a pivotal moment in our journey to support health and care transformation across United Kingdom, Northern Ireland and Republic of Ireland. We are committed to partnering with Irish health leaders to deliver innovative, sustainable solutions that improve outcomes for patients and communities. Our team brings deep expertise and a passion for excellence, and we look forward to working together to shape the future of healthcare across the island of Ireland. Tony McNamara, our Associate Director, reflects on the current landscape of the Irish health system and the interplay between public and private services.” – Sarah Pinto-Duschinsky

Structure of the Irish Health System

The Irish health service is a mix of public and private medicine in both the hospital system and in community services. This is evident in that 46% of Irish citizens contribute to private health insurance schemes, equating to c. 2.5m people and 32% of the population have medical cards, entitling them to free healthcare. A further 13% of the population have access to free GP care and some of these people and medical card holders, exercise their right to register for private health cover.

Sláintecare and Evolving Contract Models

In 2017, Slaintecare (1), a vision for the health system in Ireland, was published as a policy to which virtually all political parties subscribed. It promoted a shift in care from the hospital system to community services, including the implementation of public only contracts for consultants employed by the public service and working in public hospitals.

In 2018, I wrote an Opinion Editorial in the Business Post arguing against the withdrawing of private practice from public hospitals in Ireland. I subsequently lost the argument. Public only clinical consultant contracts were introduced in 2023 and at this point, over 64% of Health Service Executive consultants have signed these contracts (2).

These contracts provide for a range of basic pay from €233k to €280k and provide an option for the consultant to avail of rights to practice privately in private hospitals outside of their 37 hours per week commitment.

Impact on Service Delivery and Expansion of Private Provision

It is too early to say at this stage whether this contract represents good value for money for the taxpayer in terms of reduced waiting lists, improved productivity or more streamlined patient pathways to improve patient flow. However, what can be observed is that private hospitals have been extremely adept at pivoting to increase the range of services that they can provide for patients availing of their offerings. This adeptness, contrasts with the time taken in the public system to build infrastructure or to rapidly develop services optimally to meet patient needs and notably, the practice of contracting work to the private sector, commenced in earnest during Covid, is now a regular part of the system as has been insourcing until recently.

Growth in Public Funding and Ongoing System Challenges

In 2019, the revenue budget for health services in the public service was c. €16bn and it is now €26bn an increase of almost 63% (3). Undoubtedly, some of this increase is accounted for because of embedded, incremental pay increases but, as in the case of the public only consultant contracts, there is a need for a debate as to whether there have been improvements in the public health system, commensurate with very substantial improvements in funding.

As with very many other health systems the Irish health service faces challenges in respect of financial management, optimisation of procurement and supply chain management, migration to digital systems and optimisation of integration to mention but a few. These challenges are not unique to the Irish health service but will demand high levels of leadership and commitment to change.

Conclusion

In any event, problems in the Irish public health system, cannot be laid at the door of insufficient funds, rather, and the Minister for Health is correct to observe, it is a matter of performance management, and it is only right that there should be a debate on this fundamental issue.