Report calls for halt to hospital trusts and rethink on universal health insurance

Official approach to reform is “repeating mistakes of failed HSE experiment.”

A research report published by IMPACT trade union today (Thursday) says patient safety and service quality is being put at risk because independent hospital trusts and other new health structures are being implemented before fundamental issues are resolved. The Future of Healthcare in Ireland says hospital trusts are being established before funding and staffing levels are agreed and without proper consideration of integration with primary health care and other non-hospital services. It calls for the roll-out of hospital trusts to be halted until these issues are resolved.

The report, by independent healthcare expert Dr Jane Pillinger, also says official plans lack clarity on how new national directorates – for primary care, mental health, hospitals and social care – will interact with each other, particularly when serving clients with multiple needs. Under Government plans, the new directorates and hospital trusts will replace HSE structures.

The report is equally critical of the Health Minister’s preferred model for universal health insurance (UHI), which it says is unlikely to deliver value-for-money or the Government’s ambition of universal access to healthcare.

Dr Pillinger says the Government’s UHI model carries inherent financial uncertainties that could put critical services at risk. “The Government has based its approach to UHI on policy in The Netherlands where a system of competing private insurers has created an inequitable and inefficient system of funding, different tiers of entitlement, rising hospital deficits, and even bankrupt hospitals,” she said. Inherent financial incentives to discharge patients early has also led to one of the highest hospital readmission rates in Europe because more people experience post-discharge complications.

The report urges the Government to revisit the funding of UHI by evaluating an alternative ‘single-payer’ social insurance model like those used in France, Germany and Nordic countries. “The ‘competing insurers’ model should not be adopted before all the options have been evaluated in terms of quality, equity, access to services, and medium and long term value-for-money,” it says.

Speaking at the launch, Dr Pillinger said: “The last major structural health service change to be rushed through was the creation of the HSE in 2005. The same risky mistake is being repeated, with fundamental funding and structural changes being implemented hurriedly and without proper consideration of risk or the potential impact on services. This is likely to have similarly painful results for patients, service-users, staff and taxpayers as the failed HSE experiment.”

The detailed critique of Government plans argues that new governance and funding structures should not be implemented until a range of existing underlying problems and priorities – including the shift of funding to primary care, preventative and mental health services – are addressed. It also highlights the need for more systematic improvements in financial management, quality assurance and integration across health services, and calls for a more systematic approach to determining service entitlements, staffing levels and staff-population ratios.

IMPACT national secretary Louise O’Donnell said health staff acknowledged that the Government is bound by budgetary constraints imposed by the Troika. “But current budgetary restraints are no justification for adopting the wrong model for a generation or more of public health service users,” she said.

Ms O’Donnell said the health system was unable to meet the needs of the population because of historical underfunding, perennial and growing HSE deficits, long waiting times for many services, the inequitable two-tier system and cuts resulting from the troika-imposed budgetary policy. “These are exacerbated by demographic changes and the increasing cost of new medical technologies. The Croke Park agreement has been crucial in managing cuts in resources and staffing. Nevertheless, they inevitably have a negative impact on services and staff morale,” she said.

The report is strongly critical of the lack of consultation about health service changes with the communities, services users and staff who are most affected. It calls on the Government to instigate “active consultation measures including ‘town hall meetings’ to elicit the views and priorities of communities and health service users before radical reforms were introduced. “The Minister’s radical plans for healthcare reform are being shaped out of public sight and without full consultation with stakeholders,” said Ms O’Donnell.

The report also calls for multi-annual funding for health services and an independent assessment of staff-patient ratios across all services.

Read the full report HERE


  • Health policy and its implementation must be underpinned by commitments to social solidarity, respect, trust, universality, accessibility, quality and value-for-money, including the role of healthcare in reducing broader inequalities in society.
  • An independent assessment of appropriate staff-patient ratios across all services should be carried out. Current ratios should be measured against these to identify the shortfalls.
  • A single payer social insurance model, along the lines of those used in France, Germany and Nordic countries should be considered and evaluated in detail before the Government’s white paper on financing UHI is issued. The ‘competing insurers’ model should not be adopted before all the options have been evaluated in terms of medium and long-term value-for-money, quality, equity and access to services.
  • The Government should instigate active consultation measures, including ‘town hall’ meetings, to elicit the views and priorities of different communities and service users, and to harvest the skills and experience of health staff and professions. These meetings should set out the government’s plans for UHI and governance structures with information about all the models examined by the Government.
  • New governance and funding structures should not be implemented until existing underlying problems and priorities are addressed. Central to this is to shift the balance of funding to primary care services, preventative care services and mental health services. Crucially this means investing in a public healthcare system and ending the drive towards more privatisation.
  • More attention needs to be given to systems for financial management, accountability, quality assurance, shared services and integration and coordination across the healthcare system, including for ICT systems.
  • No matter what budgetary constraints exist, health service funding should be put on a multi-annual basis to improve and facilitate proper planning.
  • A more systematic approach to collecting data on service use and demand, including in the community and voluntary sector, is essential to service planning and should be implemented as a priority.
  • Full consultation over the staffing and industrial relations implication of changes in health structures and funding should be undertaken with the appropriate unions.
  • The Therapy Advisory Group, along the lines of the Medical Council and Nursing and Midwifery Units, should be reinstated to ensure that all health professionals have an effective role in workforce planning and redeployment.