Implementing Social Health Insurance in Ireland

What happens next

Our meeting went well, with just under 50 delegates attending. Many thanks to all those of you who struggled through the snow to it, and my sympathy to those who couldn’t make it. I’ve added the slides from each speaker here. I also recorded the presentations. For obscure reasons two of these recordings worked, and two did not, but the ones which worked will be up shortly.

We have now prepared a final report from the meeting which is here. This started as a set of notes from each working group, which Anthony Staines drafted into a document which was sent around twice for review by the speakers and contributors. Many thanks to all. The Irish Times also published an opinion piece based on this work.
Creative Commons License
Implementing Social Health Insurance in Ireland by Anthony Staines and contributors is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

List of speakers and links to their slides

DateMonday December 6th
Time10am to 4pm
LocationJury's Inn, Custom House Quay, Dublin.

How can we deliver a fair, affordable health care system to the Irish public?

The woes of the Irish health services are well known. There has been an endless series of bad news stories from the service. The more fundamental issues are also well understood. Recent books by Sara Burke, Maeve Ann Wren, and Maeve Ann Wren and Dale Tussing have identified the issues with great clarity. In addition, two recent reports on resource allocation, one from Anthony Staines and colleagues in DCU and a blockbuster from Frances Ruane and colleagues in the ESRI have explored the financing of the Irish system in great depth.

Our health care system is, we believe, fundamentally flawed, and further tinkering around the edges will get us nowhere. A radical revision of how we deliver, pay for and organize health care is needed; a system which eliminates, once and for all, the two-tier system of health care; a system which puts patients at the heart of the service; a system which builds out from primary care.

The most coherent policy proposal made, so far, is to introduce some form of Social Health Insurance. Recent work from Stephen Thomas, Samantha Smith, Charles Normand and colleagues in TCD, funded by the Adelaide Hospital Society has outlined the feasibility and the affordability of SHI in Ireland. We now wish to consider some of the practical implications of doing this.

Supported by the DCU School of Nursing, I’ve arranged a one day seminar on implementing SHI in Ireland. Work with us to identify the problems, and find some of the solutions, in a one day interactive workshop, with talks from leading national and international experts.


9:30Registration and Coffee
10:00Prof. Peter Groenewegen
Director of NIVEL
The 2006 health insurance
reform in the Netherlands: implementing universal coverage.
10:30Dr Steven Thomas,
Resource Allocation and the Irish Health Services.
10:45Dr. Martin White
Paying for General Practice, the past and the future.
11:00Prof. Orla Hardiman,
consultant neurologist, Beaumont
Acute care services and integrated care – a way forward
11:15Question and Answer Session
11:45Briefing for the afternoon workshops
12:30Working sessions
(Choose one)
Primary Care and General Practice
Acute Hospital Care
Long Term Care
Mental Health
Raising and allocating resources
3:00Coffee Break
3:15Plenary session

All participants will receive a briefing pack before the meeting, to allow you to bring yourself up to date on the issues facing us. We will start the day with talks from our four speakers.

  • Prof. Groenewegen is the director of NIVEL, the leading Dutch health services research institute, and has had a major influence on the implementation and evaluation of SHI in the Netherlands.
  • Dr. Steven Thomas, is a health economist and policy analyst working in the Department of Global Health, TCD. He has done extensive work on the feasibility of social health insurance in the Irish health service.
  • Dr. Martin White is a leading Irish GP, with a practice in Co. Meath.
  • Prof , Orla Hardiman is a consultant nerologist, and a HRB clinical Scholar, with many years experience working in, and trying to improve, the Irish health services.

Then we will split into smaller working groups, covering Primary Care and General Practice, Acute Hospital Care, Long Term Care, Mental Health, Raising and allocating resources, each of which will report back to a final plenary session. A report from the meeting will be published, but will be circulated to all participants for comments first.

Full details, and the registration form are in the Flyer (pdf).
Registration is free, but places are strictly limited, so early registration is advised.
The Chatham house rule applies.


The Irish health system European Observatory report
Here you will find a detailed description of the Irish health services
The Netherlands health system European Observatory report
Here you will find a detailed description of the Netherlands health services.
Evaluation of the Health Insurance Act
Here is an evaluation of the recent changes in the Netherlands, by Peter Groenewgen and colleagues.Please read this!!
Adelaide Hospital Society 1 : Social Health Insurance, Options for Ireland 2006
This is the first in set of reports from Steve Thomas and Charles Normand.
Adelaide Hospital Society 2 : Social Health Insurance, Further Options for Ireland 2008
This is the second report, written by Steve Thomas, Charles Normand and Samantha Smith
Adelaide Hospital Society 3 : Effective Foundations for the Financing and Organisation of SHI in Ireland 2010
This is the third report, written by Steve Thomas, Padhraig Ryan and Charles Normand
Adelaide Hospital Society 4 : Policy Paper 2010
This is the (short) policy paper drawing on the work of the other papers. Please read this!!

11 comments on “Implementing Social Health Insurance in Ireland

  1. Cormac MacGowan says:

    Hi Anthony,

    Thank you for responding.

    As it happens, even though, at one point in my career, I negotiated on behalf of companies with Trade Unions, I recognise that there is an important role to be played by the Unions to the benefit of the public.

    Unfortunately, they’re stuck in an anachronistic mode of creeping “improvement” to conditions of narrow groups of members. It is a useful tactic, in a short-term context. However, in the medium to long term it is toxic for members (who’ve now had to take substantial hits in income, partly as a result), and for society in general – which has to fund these “improvements”.

    For example, it leads to the situation where the exact same role has different wages and conditions depending on where you are in the country – from working hours, to expenses, to range of duties, and so on. Managing this profusion of difference renders efficiency impossible. (This was why the PPARs project ran into the sand – not because consultants were involved, and not because the project was poorly conceived, but because trying to capture the constellation of different terms and conditions for the vast number of different roles requires “Rocket Science” levels of investment. Far better to cut the complexity, simplify the organisational structure to manageable levels.

    It also leads to crazy situations where Unions sit on hiring panels, and Union exams have to be passed in order for people in the public service to advance.

    The situation in which managers are part of the same Union structure creates a conflict of interest situation.

    But the main problem is that when an organisation is averse to absorbing the cost of losing an Unfair Dismissals claim, then there can be no performance management – because managers won’t make decisions that the organisation won’t back. There is a tendency for the EAT to lean towards workers in such cases – to do with which party has the deepest pockets, and in attempts to drive “best practice”. Tnis is all very well, but the balance has swung too far in one direct.

    So, if there is no willingness in the public service to dismiss people for failing to perform, or for misconduct, or refusing to engage in change, then no real change is possible, because management have no ultimate authority.

    I know of many situations in the public health service where monumental waste is tolerated – from complete lack of control in supply chain management, leading to overstock and then wastage – to archaic practices such as paper form filling where replacement technology has existed for decades. The impact of this last activity is enormous. No management information of any use can be generated. Any information generated is obsolete. Too many manual interventions are required – increasing the likelihood of data loss, or data degradation. Effectively – no proper management is possible in this kind of situation.

    This leads to overresourcing in some places, under-resourcing in others. It means that when cuts have to be made, they’re made in the most obvious places – and this means at the front line of service delivery.

    This is a recipe for mass demoralisation, inefficiency, cost inflation, and the like.

    What we’re witnessing with the so-called “reforms” in progress will produce little or nothing in actual reform. The game continues as it always has, with a temporary blip downwards in costs for a few years – as natural wastage through retirement and resignation reduces the wage bill.

    No improvement to the quality of public health services delivered will result, or for that matter, to the quality of public services in general.

    Incidentally, in general, when operational transformation is successfully implemented, up to 30% cost reductions can be achieved. This doesn’t necessarily involve redundancies – merely the idenfitication of wasteful activities, and their removal from the processes. 30% is not an overly ambitious target in such projects. But even a 15% reduction in the cost of the public service bill would be far in excess of what the government can achieve in their current approach – because it would be a 15% cheaper public service every year.

    Root and branch reform is required. This government doesn’t have the bottle, or it seems the imagination or ambition – even though they’ve the biggest mandate any government has ever had in the history of this state to achieve real change.

    The Unions are still locked in their anachronistic narrative, and will not be capable of moving outside it.

    It is a shame.


  2. astaines says:

    Very good question. I tend to agree with you, up to a point. I see three converging problems which have led to the present impasse. First, is fairly uninspired political leadership, more focused on reportage than the delivery of service change. Second is poor management, leading to a really toxic culture in both HSE and DoHC. Third, is indeed, poor quality trade unions. I have been a union member since I was 16, and I still am. I’ve been a local and national union rep, and I even ran a strike once, so I’m no hard-right union-basher, but we do have a problem.
    What to do about it? Leadership can deliver a lot, but only of staff are willing to be led. My 2c. is that staff are very frustrated, and mostly, willing to change. Will they have the courage to tell their unions this?
    Thanks for an interesting observation,

  3. astaines says:

    Very simple, only approved comments are visible, and I didn’t get around to approving it till just now.

  4. Cormac says:

    Interesting that my comment is no longer visible.

    Why is that?

  5. Cormac MacGowan says:


    I’ve read the summary of your recommendations in Volume 1 of your resource allocation model.

    Unfortunately, while there are good ideas therein, none of it can make a blind bit of difference, until the health service is capable of actually managing the operation.

    At this time, due to the influence of the unions, (in particular IMPACT), effective management is impossible. (Demarcations, Disparities in terms, conditions, and remuneration for the same jobs in different parts of the country, resistance to real performance management by both union and management, etc. etc.). All this leads to the good people in the Health Service taking all the pressure, and the lead-swingers getting away scot free.

    It also leads to massive cost inflation in both human resource and physical material terms. These lead to vastly inflated operational costs.

    We can manipulate resource allocation into the health service as much as we like. Any efficiencies gained there will quickly be eaten up by pretend jobs in administration, and in further bad practices.

    The health service, like the rest of the public service must be reformed root and branch. No sacred cows can be allowed to remain.

    If public servants are to have a job for life, then the quid-pro-quo must be complete flexibility and total openness to ongoing change. (As those of us in the private sector do).

    Public servants have been hit hard in their pay packets, my wife included. This is the unfortunate result of allowing unions a free hand in the operation of the public service, absolute failure to manage, (at all levels), and the rampant creation of non-jobs.

    This is not to say that there aren’t good and conscientious workers in the public service – there are. But unfortunately for them, they carry the can for all the dross and poor practices. It would be an act of kindness to lift this burden from them.

    How will your proposals address these issues?

    Kind regards,


  6. […] More detail of our report, and a number of useful resources are found elsewhere on this website. […]

  7. Kamila Mahadevan Doyle says:

    Hi Anthony Staines and Fergus O’Ferrall

    I am really looking forward to monday, I hope none of us get snowed in on the w/e.


    Kamila Mahadevan Doyle

  8. Fergus O'Ferrall says:

    Anthony- well done on organising this day which I plan to attend. I have a number of Conferences to address on this key reform and there is obvious growing interest in using the present set of crises to achieve fundamental reform. In Adelaide Hospital Society we have been researching and advocating the necessary changes for a number of years as you know and we are confident that it now has political traction – the key is to present the reforms clearly and achieve tangible benefits quickly. Other countries have done it and so can we! Looking forward to the day!
    Dr.Fergus O’Ferrall
    Adelaide Lecturer in Health Policy, Trinity College, Dublin.

  9. […] Anthony Staines is running a seminar on social health insurance on 6 December – check out here for more […]

  10. astaines says:

    Believe me I quite understand! – could you pass on the details to any interested parties? I don’t think I have the energy to do another of these, but if someone else organizes one I’d be delighted to come.

  11. Bill Shannon says:

    Dear Anthony,
    Much as I believe in the whole drive towards SHI I cannot see myself taking a full day off on Monday Dec. 6th from my workplace here in the University of Limerick Medical School. I wish you every success with your deliberations on the day and look forward to supporting your movement.
    Bill Shannon
    PS Any chance of holding a Regional meeting/workshop in the Mid-West?

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