What is the true cost of the NTPF?

During a general motion debate on the future of Sláintecare at the IMO AGM in April, the subject of the National Treatment Purchase Fund (NTPF) came up.

Speaking from the floor, Dr Anthony O’Connor, Consultant Gastroenterologist, Tallaght University Hospital, Dublin, and former Medical Independent (MI) columnist, expressed skepticism about the extent to which Sláintecare was being implemented.

“The biggest shift we’ve seen, just being factual about it, over the last seven to eight years, is the increase at warp speed of outsourcing,” Dr O’Connor said.

Dr O’Connor was referring to the NTPF and its responsibility for arranging treatment for public patients languishing on waiting lists.

He noted how the budget of the Fund is now over €230 million, which is similar to that of a model 3 hospital.

“I think we really need to question the value for money we are getting there.”

He pointed out that neither outsourcing to the private sector, nor indeed the Fund, was referenced in the original 2017 Sláintecare document.

The NTPF was established just over 20 years ago in 2004. Its original responsibilities included the sourcing of hospital treatment for long-waiting patients, predominantly in the private sector, and the collection and validation of information in relation to waiting lists.

The NTPF’s role was extended in 2009, through the Nursing Home Support Scheme Act, to provide for negotiations with private nursing homes in the context of fees.

During its initial years, the Fund faced strong criticism, particularly for its purchasing of treatment within the private sector. The Fine Gael Health Spokesperson at the time, Deputy James Reilly, repeatedly highlighted the issue. When he became Minister for Health following the 2011 election, he vowed to downsize the body.

Shortly after taking office, Minister Reilly said: “It is unacceptable that hospitals leave some patients on waiting lists for very long periods of time safe in the knowledge that the NTPF will eventually pick up the tab.”

He wanted public hospitals to take greater ownership of their waiting lists and established a special delivery unit (SDU) to support this.

However, as the country was struggling to emerge from recession, hospital budgets were impacted and waiting lists increased.

Following the 2016 election, use of the NTPF to help tackle hospital waiting lists was ‘reactivated’ under the confidence and supply arrangement between Fine Gael and Fianna Fáil. Minister Reilly’s SDU was quietly forgotten.

The budget for the Fund started to rise, amounting to €100 million in Budget 2020.

Speaking to MI before the general election that year, the Fianna Fáil Health Spokesperson, and soon-to-be-Minister, Stephen Donnelly, credited the NTPF for preventing waiting lists from spiraling out of the control.

“The only thing that is stopping the entire system from collapsing is the NTPF over the past three years,” he said.

Mr Donnelly said his party wanted an “emergency” response to the deficits in healthcare, in tandem with delivering Sláintecare over the longer term. And, after the election, the responsibility of the Fund grew and grew.  

In 2025, with another new Government in place, the NTPF does not seem to be part of an emergency response (if it ever was), but rather an intrinsic part of the healthcare landscape.

It has recently been in the news for the wrong reasons, as a result of alleged irregularities in how ‘insourcing’ was conducted in Children’s Health Ireland and Beaumont Hospital.

But few are questioning how the Irish health service has become so reliant on the NTPF, or how its work outsourcing to the private sector is in line with the ethos of Sláintecare.

According to the waiting list figures for May, there has been a 5 per cent reduction in the total number of patients waiting over 12 months since the same period in 2024, and a corresponding reduction of 12 per cent in the number waiting over
18 months.

The Department of Health says the health service has seen significant longer-term improvements in waiting times since the multi-annual waiting list action plan approach was initiated in September 2021.

It should be acknowledged the NTPF has been central to this. And given the continuing substantial capacity deficits in healthcare, which have been highlighted in new Economic and Social Research Institute reports, its role is unlikely to change anytime soon. But it is worth asking whether the Fund has become an expensive crutch that is holding back genuine systemic reform – and if its increasing responsibility is helping entrench some of the inequalities Sláintecare set out to eliminate.