CHI review identifies a range of systemic issues

Our previous editorial focused on recent controversies concerning the implementation of the public-only consultant contract (POCC), namely in the Rotunda Hospital, Dublin.

The POCC is one of the issues referenced in the recently published Review on Governance and Equity in Patient Access and Waiting List Management at Children’s Health Ireland (CHI).

The audit, which was commissioned by the HSE and conducted by the consultancy firm EY, was undertaken following concerns raised in previous reviews.

The aim of the audit was to examine governance, access to care, and payment practices, as well as waiting list and National Treatment Purchase Funding (NTPF) oversight. It also assessed the balance between public and private patient management in the period between January 2023 and May 2025.

The audit reviewed three specialties: Orthopaedics, including spinal services; urology; and respiratory medicine. It examined processes for patient referral pathways, waiting list administration, and whether CHI’s waiting list action plan, or NTPF-related initiatives, met the required conditions for funding.

On the positive side, the report found no clear evidence of inequity in access to care between public and private patients.

However, this finding was “constrained by significant limitations in data availability, classification, and sample size”.

In the main, the audit outlined a number of systemic issues affecting waiting list governance, transparency, and assurance.

For example, it found that patients in the samples assessed were treated outside the NTPF clinical recommended timeframes (CRTs) across all three specialties reviewed.

“These delays affected urgent, semi-urgent and routine patients,” according to the report.

Also, documentation relating to waiting list management across the specialties reviewed was often incomplete or inconsistent.

The review stated the clinical prioritisation category (CPC) was not consistently recorded on booking forms, referral letters, or other source documentation.

“In some cases, urgency had to be inferred from planned procedure dates or indicative follow-up timeframes; in others, the CPC recorded on the integrated patient management system (IPMS) did not align with the source documentation,” it found.

Waiting list records across the specialties reviewed contained a number of inconsistencies and data quality issues, with discrepancies noted between IPMS data and source records.

There were also gaps in how NTPF and HSE-funded initiatives were governed and a standardised framework to define and measure core activity had not been established.

“Broader limitations in data management, policy governance, and control structures were identified, including fragmented systems, incomplete records, and inconsistent processes,” according to the review.

The future and scope of private practice in CHI was an area that had yet to be adequately defined.

The review noted that – in the context of the roll-out of the POCC and the opening of the New Children’s Hospital – revised arrangements for consultant private practice were being progressed. CHI also has contractual obligations to facilitate private practice for consultants holding type B contracts.

“However, the overall model remains under development, with key elements such as service arrangements and fee structures (between consultants and CHI) yet to be finalised,” according to the report.

It recommended that CHI should establish a centralised repository for consultant contracts, work plans, and associated documentation. The repository should be complete, regularly updated, accessible to authorised employees, and subject to review.

“Furthermore, CHI should implement risk-based monitoring arrangements for consultant contractual obligations, particularly for consultants who remain on legacy contracts that permit private practice.”

It also says that CHI should have a policy that “clearly prohibits or regulates” the referral of public patients from public outpatient settings to private outpatient services.

Overall, the review found services working “under considerable pressure” in an environment “that has not kept pace with the complexity of services”.

In response to the review, CHI has developed a quality improvement plan with 26 actions. Of these, 65 per cent are complete and 35 per cent are partially complete.

The report is worth reading and the findings may have relevance for other parts of the health service outside CHI.