Two-Tier Health System
Access to healthcare is severely undermined because of Ireland’s entrenched two-tier healthcare system, meaning that those with higher incomes have better access to healthcare. The healthcare system has its origins in 1950s Ireland when the Voluntary Health Insurance Board (VHI) was established as a state-backed monopoly to cater for the 15 per cent of people at the top of the income distribution scale who did not have an entitlement to State hospital care.1 The structure was designed to ensure that ‘the entire population had access to hospital care while satisfying the demands of medical consultants that their private practice not be undermined’.2 Due to improved incomes nearly half of the population took out health insurance.3 Attitudinal surveys reveal that this was due in part to concern about waiting times in public hospitals.4
The overall result is that those on low incomes have to wait for extended periods for procedures through the public system, while people who can afford health insurance can ‘jump the queue to get a much faster service’ through the private system.5 Patients going through the public system are often subjected to waiting lists and delays, while those with greater resources and health insurance get faster treatment often on public hospital sites because the Irish system allows doctors to use public healthcare facilities to run private clinics.
Despite a government commitment to introduce a universal healthcare system,6 a commitment which is now under review,7 a two-tier system still operates. In 2013, 45 per cent of the population had private health insurance compared to 51 per cent in 2008.8 Uninsured people are three times as likely to live in a household where someone has lost a job while almost two thirds of people who had given up their private health insurance cited cost as the main reason.9 The number of employees who benefit from subsidies or provision of health insurance cover by employers has decreased from 41 per cent in 2011 to 32 per cent in 2013.10 Increases in private insurance premiums and government-led changes to tax reliefs implemented as part of the Troika agreement have also impacted on people who were still able to afford some level of health insurance.
Figure 5: Case study – Two-tier health system causes death due to long waiting lists
Susie Long’s case highlights the devastating impact of the two-tier healthcare system.11 In the summer of 2005 Susie, a mother-of-two in her late thirties, was referred for a colonoscopy following a consultation with her GP. She did not have private health insurance so waited seven months on the public waiting list. By the time she had the test, she was diagnosed with terminal bowel cancer as the cancer had spread while she awaited diagnosis and treatment. Susie discovered from a fellow patient who had private health insurance that she had been diagnosed within three days of a GP visit and was expected to recover from the illness. Susie highlighted her case in the media to draw the distinction between treatment of private and public patients. Before her death in October 2007, Susie had to move to Dublin as there were no available hospice services in Kilkenny.
Waiting lists and delays for emergency and public patients
At the end of 2013 there were 48 acute hospitals operating with 11,513 in-patient beds and 2063 day places.12 In 2014, there are a significant number of people waiting for in-patient care and day procedures as well as on out-patient appointments as indicated in the following table.
Figure 6: Hospital waiting times 2014
Hospital waiting times 2014
In-patient and day cases
More than 3 months
More than 6 months
More than 12 months
Source: National Treatment Purchase Fund – Hospital Trend Analysis of Waiting Times13
Hospital overcrowding remains a serious issue. In August 2014, just over 2100 in-patient beds were closed14 while figures for July 2014 show that 4449 patients were forced to remain on trolleys in Emergency Departments due to bed shortages, a 26 per cent increase on 2007 figures.15 In 2013, a total of 57,286 admitted patients were forced to wait on trollies while more than 10,500 patients were placed in beds, chairs or trolleys on wards without sufficient spaces in the last nine months of the year.16
Figure 7: Number of people waiting on hospital trolleys July 2007-July 2014
Source: Irish Nurses and Midwives Organisation Trolley Watch Figures 2007-2014
Although patients who no longer require hospitalisation should be discharged as soon as possible, the lack of financing for community-based services as well as step-down and long-term facilities means that many patients, in particular older patients, spend prolonged periods in hospital unnecessarily.17
Despite Government’s commitment to reform the primary care system,18 only a fraction of the Health Service Executive’s overall budget is allocated to these services: €726 million out of an estimated €13.1 billion in 2013.19 The target of 530 Primary Care Teams, due to be in place nationwide by 2011, has not been achieved.20 There is no clear legal basis for access to primary care teams or community therapy teams – currently these teams are often only available for medical card holders – and they are provided subject to budget caps and resource constraints.21 Other community-based services are similarly subject to budget caps.22 Furthermore, the low distribution of General Practitioner doctor services in disadvantaged urban and rural areas has been linked to the current payment system for GPs which encourages them to locate their practices in areas with more favourable health and social profiles and a higher proportion of private patients.23
Mental Health Services
In 2014, the Government failed to honour its commitment to annually ring-fence €35 million of the health budget to develop community mental health teams24 as it allocated only €20 million.25The Mental Health Commission, a statutory body established to promote high standards in the delivery of mental health services, suffered a funding cut of 36 per cent of its operating budget between 2007 and 2012.26 However, there is a clear demand for greater access to mental health services particularly in times of recession. The National Suicide Research Foundation has found evidence of a link between the impact of the recession and a higher rate of suicide, such as loss of employment, financial difficulties and loss of possessions including a person’s house.27 In 2013, there were a total of 475 registered suicides, 83 per cent of which were men.28
In 2013, 13,377 people were admitted to adult acute units, a slight decrease of two per cent since 2012.29 However, the number of involuntary admissions rose by five per cent in the same time period to 1741 people.30 Increased demand on the 62 Child and Adolescent Mental Health Services (CAMHS) teams in operation led to a six per cent increase in referrals while the services have seen 12 per cent more new cases in 2014 compared to the year before.31 In May 2014, 525 children or young people were waiting for more than a year for a first appointment with the Child and Adolescent Mental Health Services.32 In 2013, some 332 children and young people were admitted to approved mental health facilities but 91 children (22 per cent of the overall figure) were inappropriately placed in adult facilities.33 This trend continued in 2014, with 27 children or adolescents (34 per cent) admitted to adult facilities in the first five months of the year.34 This is largely due to the lack of adequate child-specific facilities; only 56 out of 66 beds were available in the six Child and Adolescent Acute Inpatient Units.35 Given the higher numbers admitted to adult facilities there is a clear need for more age-appropriate accommodation.
In the first six months of its operation, 5000 referrals were made to the newly established HSE Counselling in Primary Care service (CIPC).36 However, in 2014 the service received less than one per cent of the overall mental health budget despite having the potential to reduce the number of individuals referred on to specialist mental health services or to encourage a return to work for people suffering from emotional or mental distress.37 Furthermore, the service is only available to medical card holders for a maximum of eight sessions and can only be accessed through GP referral.
Article 40.3.3 of the Irish Constitution recognises the right to life of the unborn and provides protection for that right ‘as far as practicable’ with ‘due regard to the equal right to life of the mother’. Legislation was passed in July 201338 to allow for terminations in the limited circumstances where there was a real and substantial risk to the life of the mother, including in circumstances where the mother is suicidal. In other circumstances, abortion remains a crime in Ireland.39
Other UN Treaty Bodies have made recommendations on the issue, including a recommendation by the UN Human Rights Committee in 2014.40 Separate submissions will be made to the Committee on this issue.
FLAC urges the Committee to recommend that the State:
Provide adequate resources for acute, primary care and community-based services to ensure people can access appropriate care and treatment in a timely way.
Provide adequate resources for mental health services including the full amount of development funding as outlined in the Programme for Government.
Ensure no child or young person is placed in an adult facility and increase financial support for the Child and Adolescent Mental Health Service to cope with demand and ensure that no child or young person is left waiting for essential mental healthcare.
Resource mental health supports and prioritise non-coercive forms of treatment and alternative pathways to mental health recovery, based on peer support.
Ensure that contraception is both accessible and affordable for people on low incomes who require it.
1 A. Nolan and B. Nolan (2005) Ireland’s Health Care System: Some Issues and Challenges, Dublin: Economic and Social Researc Institution, pp.82-83.
2 A. Nolan and B. Nolan (2005) Ireland’s Health Care System: Some Issues and Challenges, Dublin: Economic and Social Research Institution, p.83.
3 A. Nolan and B. Nolan (2005) Ireland’s Health Care System: Some Issues and Challenges, Dublin: Economic and Social Research Institution, p.83.
4 A. Nolan and B. Nolan (2005) Ireland’s Health Care System: Some Issues and Challenges, Dublin: Economic and Social Research Institution, p.83.
5 B. Harvey, (2007) Evolution of Health Services and Health Policy in Ireland, Dublin: Combat Poverty Agency, p. 12.
6 Department of Health, ‘Health Ministers Publish Future health: a strategic framework for reform of the health service 2012 – 2015’, [press release], 15 November 2012.
7 P. Cullen, ‘Varadkar review casts further doubt on future of universal health insurance’, The Irish Times, 8 August 2014.
8 Health Insurance Authority (2014) Market Statistics: February 2014, Dublin: HIA.
9 Health Insurance Authority (2014) The Private Health Insurance Market in Ireland 2014: Consumer Survey, Dublin: HIA, p.5.
10 Health Insurance Authority (2014) The Private Health Insurance Market in Ireland 2014: Consumer Survey, Dublin: HIA, p.7.
12 Health Service Executive (2014) Annual Report and Financial Statements 2013 Report, Kildare: HSE, p.14.
16 Irish Nurses and Midwives Organisation (2014) INMO trolley and ward watch analysis 2006 – 2013, Dublin: INMO.
17 Social Justice Ireland (2014) Socio-economic Review 2014. Dublin: Social Justice Ireland, p.176-8.
18 Government of Ireland (2011) Programme for Government 2011-2016, Dublin: Stationery Office, p.32.
19 Health Service Executive (2013), National Service Plan 2014, Dublin, HSE, p.20.
20 Social Justice Ireland (2014) Socio-economic Review 2014. Dublin: Social Justice Ireland.
21 Department of Health (2014b) Background Policy Paper on Designing the Future Health Basket.
22 These include home help, home care packages, respite and convalescent, day care, meals on wheels and elder abuse services.
23 R. Layte, A. Nolan and B. Nolan (2007) Poor prescriptions – poverty and access to community health services. Dublin: Combat Poverty Agency, p.102.
24 Government of Ireland (2011) Programme for Government 2011-2016, Dublin: Stationery Office, p.36.
25 Health Service Executive (2013) Health Service National Service Plan 2014, Dublin: HSE.
26 Mental Health Reform (2014) Submission for Budget 2015, Dublin: Mental Health Reform, p.6.
27 Dr. E. Arensman et al (2012) First Report of the Suicide Report and Information System, Cork: The National Suicide Research Foundation, p.8.
28 Central Statistics Office, ‘Births, Deaths and Marriages in 2013’ [press release], 30 May 2014.
29 Health Service Executive (2014) Health Service Performance Assurance Report: May 2014, Dublin, Health Service Executive, p.46.
30 Health Service Executive (2014) Health Service Performance Assurance Report: May 2014, Dublin, Health Service Executive, p.46.
31 Health Service Executive (2014) Health Service Performance Assurance Report: May 2014, Dublin: Health Service Executive, p.46.
32 Health Service Executive (2014) Health Service Performance Assurance Report: May 2014, Dublin: Health Service Executive, p.46.
33 Mental Health Commission (2014) Mental Health Commission Annual Report 2013 including the Report of the Inspector of Mental Health Services, Dublin: Mental Health Commission, p.32.
34 Health Service Executive (2014) Health Service Performance Assurance Report: May 2014, Dublin, Health Service Executive, p.46.
35 Health Service Executive (2014) Health Service Performance Assurance Report: May 2014, Dublin, Health Service Executive, p.46.
36 Mental Health Reform (2014) Submission for Budget 2015, Dublin: Mental Health Reform, p.6.
37 Mental Health Reform (2014) Submission for Budget 2015, Dublin: Mental Health Reform, p.6.
38 The Protection of Life During Pregnancy Act 2013.
39 The legislation repealed Sections 58 and 59 of the Offences Against the Person Act 1861 but it continues to criminalise women who seek abortions who may face up to 14 years imprisonment.
40 UN Human Rights Committee (2014) Concluding Observations under the International Covenant on Civil and Political Rights: Ireland, Geneva: Office of the High Commissioner for Human Rights, para. 9.
Last Updated: 22/01/2015 ^ back to top