The fallout concerning the use of funding from the National Treatment Purchase Fund (NTPF) in a Children’s Health Ireland (CHI) hospital continues.
The story that emerged in the media over a week ago painted a picture of a rolling crisis, after a confidential internal report raised concerns about abuse of waiting lists and a toxic work culture. That report will now be referred to gardaí by the HSE.
The report in question focused on five special weekend outpatient clinics for 179 children carried out by a consultant at a public hospital. These clinics were funded by the NTPF and the consultant received €35,800 for seeing the patients. However, the report questions whether the young patients could have been seen during the consultant’s HSE contracted hours or referred to his colleagues.
There were also concerns about potential clinical failures regarding vulnerable children, who may have been left waiting longer than they should have been for important treatment.
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And yet again, the report raises serious questions about professional ethics, conduct and clinical care in CHI, coming hot on the heels of the publication of two separate damning reports on children’s orthopaedic surgery failures.
We still know don’t exactly what actions were taken to address the alleged potential misuse of NTPF funds and whether there may be further similar cases in CHI. The news that the report has been referred to gardaí – amid temporary pausing of NTPF funding, which is now due to be lifted “imminently” – and promises of action and reviews, as well as the “ongoing” roll-out of a new central referral management system for all services in CHI, suggests that there is much more to come.
Whatever happens, it is unacceptable if the Department of Health, the Minister, the NTPF and the HSE were left in the dark about the whole affair until it was reported in the media, as has been suggested.
We are expected to accept promises that it won’t happen again, that action is being taken, and – well, you know the drill. But what about the bigger picture – oversight and transparency on how we are spending our healthcare budget, and, crucially, if it is being best used to provide care for patients?
This year the HSE has a record €26.9 billion in funding, and staffing levels have increased by 23 per cent in the last five years. There are many new services, and bed numbers are continuing to grow to meet escalating demand. Our population is now 5.3 million.
The Irish health system seems inexplicably reluctant to carry out routine audits and set standardised targets, as the continued large variations in productivity between services, gaps in basic performance data, and resistance to many oversight initiatives shows
The question is whether we are getting the best value for money and access to services commensurate with these increases in resources. And where does the NTPF fit into all this?
It was set up over 20 years ago to help relieve waiting list pressure in the public system, and was regarded by some as a sort of pressure safety valve to get public patients seen, diagnosed and treated faster; and by others as a sticking plaster for inadequate public capacity.
Its budget for this year is an increased €230 million. Last year it facilitated outpatient appointments, diagnostic scans and procedures for approximately 251,000 public patients. It initially purchased appointments in the private sector for patients waiting too long on public waiting lists – known as outsourcing – but in recent years it has moved towards increased use of “insourcing”. This is essentially overtime: using spare capacity in public hospitals over and above core activity.
All governance for insourcing remains with the treating hospital, the NTPF took pains to point out last week. So it, and by extension the HSE itself, claims no responsibility for how its – or rather public – money is spent, once the forms are filled in. The NTPF does publish data on how many procedures and appointments it has paid for, which is more information than many of our health services publicly provide. And now it has written to all public hospitals with whom it funds insourcing work to obtain further confirmation that all work is carried out in line with agreed terms.
There has always been the potential for abuse of NTPF funding as consultants can refer their own public patients to their private clinics, or public overtime. There is supposed to be data collection on how often this occurs, with the appropriate governance applied. And in cases where there are only one or two consultants in a highly specialised disease or geographic area, it makes sense to allow them to see these patients in a private/public overtime capacity if they are on a very long waiting list, to ensure timely access where needed and longer-term continuity of care.
But surely audit and inspections of the use of NTPF funding in individual institutions should be routine? Each hospital should always be able to fully account for the need for insourcing funds, proving that its own resources, and staffing time, have been maximised under allocated HSE funding. Newer contracts for various healthcare staff allow for longer core weekday working hours and weekend work as normal, but implementation has been piecemeal in some specialities and services, despite the increased cost and staffing numbers.
[ ‘Fear and distrust’: why children’s healthcare is in crisisOpens in new window ]
In this case, was the CHI hospital paying attention to how many patients were on individual consultant lists? How many they were seeing, and how long were individuals waiting before signing off the NTPF funding applications?
The Irish health system seems inexplicably reluctant to carry out routine audits and set standardised targets, as the continued large variations in productivity between services, gaps in basic performance data, and resistance to many oversight initiatives shows.
Last year, then-Minister for Health Stephen Donnelly presented data to the HSE board showing a significant drop in the average number of patients seen per consultant, with obvious ramifications for our long waiting lists. And in correspondence on the 2025 HSE budget, he asked the HSE to apply a standardised approach to maximising productivity through agreeing outpatient clinic targets for individual consultants, departments and specialities, and sharing data on outpatient numbers between consultants.
A health minister should not have to specifically request what should be done as a matter of course.
Our complicated public healthcare system, comprising public, voluntary and private overlapping services – and a combination of old and new working contracts – continues to muddy the waters of accountability and transparency. A key underpinning element of Sláintecare is the unpicking of the various conflicts and competing interests within our health service, increased governance and standardisation. Until its full implementation, whenever that is, far more oversight of all publicly funded services must be applied.
