In a presentation to a conference on the future of healthcare a couple of years ago, an anaesthetist from Cork urged that “innovative thinking” was needed to tackle the perennial problem of patients waiting long periods for hospital treatment.
This involved “thinking up something new or to think about something old in a new way”.
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.
However, he suggested there was an alternative that would incentivise staff to work additional hours within the limits of European employment laws.
RM Block
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.
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.
Unlocking unused capacity at night-time and weekends could allow tens of thousands more patients to be treated.
Hospitals already offered regular overtime to staff. But this new “third party” 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.
This “third party insourcing” 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.
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.
Over 27 months to March 2025 three had, between them, received more than €70 million. One, EHF 29 Limited, received €54.636 million. Official filings showed it was largely owned by two doctors, Ken Walsh and Clodagh Ryan.
Accounts for 2023 show that EHF 29 Limited had recorded an annual profit of €2.39 million.
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.
Its accounts for 2023 say that the average monthly number of people employed, including directors, was 576.
Among projects on which it has worked are day case surgery at St James’s 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.
It is understood as part of its operations, it recruits “suitably qualified staff” from the HSE.
Another company, Rosata Recruitment, received €10.3 million in the 27 months to March.
This company’s 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 €500,000 for that year.
The company says it has been “providing a wide range of insourced surgical/outpatient/diagnostic/endoscopy waiting list initiatives since 2020″.
The HSE said another firm, Totally Healthcare, received €5.9 million in the 27 months for insourcing projects. The company says it works with hospitals across the United Kingdom and Ireland.
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.
“All procedures will be delivered during weekends when hospital facilities are not otherwise in use”, it said.
Sinn Féin health spokesman David Cullinane described the HSE funding report as “staggering” and warned that insourcing presented risks.
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.
Governments for years had struggled with waiting lists. Taoiseach Micheál Martin as minister for health 20 years ago had established the National Treatment Purchase Fund to buy care for those waiting longest.
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.
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.
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.
Initially, in 2022, he launched a €350 million plan, which became a permanent feature in subsequent years.
Overall, the sums involved in tackling waiting lists were vast. Over four years, about €1.6 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.
Although regular overtime continued, third-party insourcing became increasingly common.
The framework on which this worked was a dynamic purchasing system introduced by the HSE.
This allowed hospitals operating a non-recurring initiative to conduct a mini-competition open to providers on the dynamic purchasing system.
A multimillion-euro private industry was about to develop inside the country’s public hospital system.
[ The Irish Times view on hospital waiting lists: Straining to stand stillOpens in new window ]
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.
But in the background, there were concerns.
In recent weeks, The Irish Times received documents which suggested that within Children’s Health Ireland (CHI), the group that runs children’s hospitals in Dublin, there had been particular unease about insourcing.
CHI paid €5.66 million to EHF 29 between 2023 and March 2025. It ceased insourcing initiatives in June.
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.
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.
Children’s Health Ireland said in a statement that its board “raised concerns regarding the concept of insourcing and the potential conflict of interest for staff, with HSE colleagues on several occasions”.
The HSE said that in 2023, a meeting was convened between it and Children’s Health Ireland representatives, including members of the CHI board, to discuss the provision and use of insourcing.
“CHI 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,” the HSE said in a statement.
Children’s 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 “in view of the challenges to patient waiting times and with HSE assurance”.
The HSE did not say whether it had alerted its board or the Department of Health to the concerns raised by Children’s Health Ireland.
However, within the HSE internal auditors began looking at insourcing arrangements in 2023 and early 2024.
In September 2024 The Irish Times reported auditors had found that two companies which received more than €1.5 million between them at University Hospital Limerick without a competitive procurement process were owned or part-owned by employees.
Over recent weeks more controversies emerged involving CHI, Beaumont Hospital and Naas in Kildare.
[ Beaumont Hospital has NTPF waiting list funding suspended Opens in new window ]
At the end of June HSE chief Bernard Gloster urged Minister for Health Jennifer Carroll MacNeill to phase out insourcing within a year. He said 83 serving or former health staff were acting as directors in 148 companies providing insourcing and outsourcing arrangements.
Carroll MacNeill is expected to decide on the future of the multimillion-euro insourcing industry within the next few weeks.
