Mr. Bernard Gloster:

I thank the Chair for the invitation to meet the Joint Committee on Health, with the Minister, Jennifer Carroll MacNeill TD, and colleagues. I note the focus is on the management of waiting lists for hospital treatment and on the insourcing and outsourcing of such treatment. I am joined by my colleagues, who have already been introduced by the Chair and the Minister. I am supported by Ms Sara Maxwell and Ms Niamh Doody.

On insourcing, when I met this committee in early July of this year, the Minister had just published the HSE review by survey of insourcing and outsourcing, which I had submitted to her. At the outset, it is important to make the distinction between insourcing and third-party insourcing, the latter of which was the main focus of the survey. This review identified the extent of third-party insourcing and outsourcing used by the HSE over a 27-month period, the acute third-party insourcing element of which was identified to be in the region of circa €91 million. That is approximately three days cash in HSE hospital terms.

While the review concludes that the vast majority of HSE activity is provided and funded through our own services and core funding, an increasing reliance on third-party insourcing has developed over recent years. The rationale for the use of third-party insourcing is accepted and it has added some valuable short-term capacity to many initiatives. Notwithstanding this, the practice also carries the risk of unintended consequences, including perverse incentives, perceived and real conflicts of interest, and reduced public confidence. Of significant note, third-party insourcing also creates barriers to Sláintecare reform, particular the five-over-seven-day work patterns, which are now a core focus of the health service.

Since the July meeting of this committee, I have had significant engagements with the Minister and many colleagues on this topic. At the start of August, I introduced new controls on the use of third-party insourcing in the HSE. I have attached these in an appendix to my statement for the benefit of committee members and the public. These immediately strengthened the control environment, allowing regions to engage in third-party insourcing only as a last resort and after following a sequence. I fully accept that the directions I have given render the use of third-party insourcing less attractive as an option. I am clear that the reliance and dependency on third-party insourcing does not bring sustainable benefit. Only once the sequence as set out in the new controls is exhausted and regions identify significant need for an access-to-care targeted initiative can third-party insourcing be used. It cannot be used for the provision or maintenance of any core service, and I am concerned that this had also become a feature at some sites. The controls apply to the providers that can be used and how they undertake their work. All of this is intended to reduce reliance on inappropriate third-party insourcing while maintaining all options for the provision of care to patients.

On outsourcing, I have recently agreed with the Minister and her Department to progress the development of a new and refreshed framework for outsourcing access-to-care work and all other private provider services, inclusive of private hospital beds. This will progress shortly and it is my hope that the NTPF can be of assistance to us in that issue.

On waiting lists, when I attended this committee in July, I outlined our focus on waiting time rather than overall list volume. This is the real measure of patient experience and our performance on waiting lists. Our overall weighted average wait time for outpatient department, inpatient and day case care, and gastrointestinal, GI, scopes combined is 6.75 months. While challenging in our target and ambition, this remains a substantially improved position and one we continue to pursue.

When I attended this committee last week, I provided the waiting list data for July. August figures are now available and can be summarised as follows. More than 32% of people, or 244,000 patients, on the NTPF reportable waiting lists were waiting within the Sláintecare target times at the end of August 2025. Some 83%, or 517,000 patients, on outpatient lists are now waiting less than 12 months. The volume of people waiting over 24 months at the end of August dropped by 13.7% this year compared to the end of August 2024, which is a total reduction of 4,200 patients. About 80% of people on an NTPF reportable waiting list at the start of 2025 are no longer waiting for access to care and our approach to tackling both ends of the lists has shown benefits. The HSE has delivered almost 6 million episodes of outpatient and inpatient care in 2024, an increase of more than 500,000 episodes of care when compared to 2022. To date in 2025, 3.4 million episodes of outpatient and inpatient day case care have been delivered. Despite increased activity, due to increased demand, the total waiting list volume at the end of August 2025 is 754,849 compared to 712,821 at the end of August 2024. If we continue with the focus and achievement on time waiting, long waiters and Sláintecare policy timelines, the number on the list becomes less relevant in health impact terms.

The OECD uses waiting times for health services to gauge a health system's performance, highlighting that long lists can lead to poorer health outcomes and patient dissatisfaction. Ireland’s progress in reducing long waiters in the past few short years has significantly and positively altered the landscape of scheduled care in our system. Patient outcomes, patient satisfaction and health service performance are three key reasons cited internationally as to why time waiting is the critical success factor.

I am satisfied that there remains an element of challenge in our management of scheduled care waiting times and, in general, access to many services. The principal aspect of that challenge is the pace of reform. For example, in 2025 we will have introduced an out-patient department toolkit in four or six sites. These demonstrate that extra capacity can be generated from existing resources. For example, Naas General Hospital had generated capacity of circa 5,000 additional episodes of care in a full year. We are discussing with the Minster the full roll-out of this in 2026. Reforms such as this and interventions like virtual care, balancing new-to-return ratios in our clinics, weekend and late evening clinics and central referrals all contribute to how we catch up on the demand over supply curve, which is not unique to Ireland. We do, however, accept that the pace of scaling reforms such as these is slower than we would wish. I am happy to discuss these matters with the committee.