Introduction
The right to healthcare is a fundamental right. According to the World Health Organisation (WHO), health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. The right to health includes not only the right to healthcare, but also, equality in access to healthcare and the power of decision-making over your own body. Article 12 of the International Covenant on Economic, Social and Cultural Rights enshrines the “right of everyone to the enjoyment of the highest attainable standard of physical and mental health” (see here). Ireland has a complex healthcare system. Since 1957, it comprises of a two-tier (General practitioner and Specialist) and mixed private-public system (Badrie, 2025).
The Health Service Executive (HSE) manages public healthcare services and receives funding from general taxation and the government. It provides a wide range of services, including hospital care, GP services, and community health services (either free of charge or at a subsidised rate, depending on eligibility criteria such as income, age, or medical need). To access private clinics and private hospitals, individuals need to opt for private health insurance (Medical Careers, 2024). 40% of Ireland’s population is covered by the General Medical Services (GMS) Scheme which ensures access to subsidized GP visits and hospital care, and, under this scheme, you are entitled to a Medical Card or a GP Visit Card (Badrie, 2025). Furthermore, all children under 8 are eligible for free GP visits, and there are plans to make free GP care available to all children under 12 on a phased basis (Government of Ireland, 2025). However, the private health system in Ireland is still more accessible, though expensive. In 2022, it was noted that 47% of the population use private insurance paying roughly €120 a month to various insurance companies like VHI, Laya Healthcare, and Irish Life Health, yet still only 12% of healthcare costs are covered (Donnellan, 2024). And, more importantly, around 20% of the population neither have private insurance or a medical card (Social justice Ireland, 2022). Many patients who are eligible for public GP care retain private health insurance as a way to access care at primary and secondary care in a timely fashion.
This two-tier and mixed system has its own drawbacks. Despite high funding of public healthcare, patients often receive delayed diagnoses and care. A patient first needs to be registered with a GP. For those who do not qualify for the GMS, they need to pay €50 or more for a visit and this cost can add up for people with an ongoing condition. Research shows that these costs can lead people to delay or avoid care, especially preventive services, which increases the risk of conditions becoming more serious over time (Badrie, 2025). People with chronic illnesses like diabetes and heart disease are particularly affected as they require regular check-ups and early diagnosis, and delays can lead to complications (Badrie, 2025). Since consultations are expensive, patients are often in a dilemma whether to consult a GP or take a home remedy, with some patients wary that they cannot afford follow-up visits. As Badrie (2025) noted:
“When people delay care, chronic conditions can worsen. Those paying privately may end up in emergency rooms for complications that could have been avoided with earlier treatment. And when that happens, it is not only worse for the patient—it is more expensive for the system. Emergency admissions and hospital stays cost more than preventive care, and this reactive approach is both inefficient and more stressful for everyone involved” (Badrie, 2025; para: 5).
The two-tier system has also resulted in more delays and waiting times. For example, Ireland’s outpatient and inpatient waiting lists have grown sharply since 2020, with the fallout from COVID-19 having had an impact. In November 2021, over 636,000 people were waiting for hospital outpatient appointments (public patients only) and 75,740 for inpatient/day-case care (Social Justice Ireland, 2022). Among them, 165,266 had waited 18+ months for an outpatient visit while 11,868 people waited for the same time for an inpatient/day visit (Social Justice Ireland, 2022). Among patients on the waiting list, the proportion waiting more than six months grew by 16% for outpatients and 30% for inpatient/day-case procedures (NTPF, 2022, cited in Ginneken et al., 2022). These backlogs have worsened since COVID-19: more than 75,700 patients have been added to waiting lists in the last four years (a 41% increase since 2019) with already 260,000 people waiting for diagnosis (Independent.ie, 2025).
Sláintecare is the HSE and Department of Health’s overall improvement plan and strategy for reforming Ireland’s health and social care system, which stemmed from a 2017 proposal to establish a universal healthcare service instead of the two-tier system. One of the main aims of the programme is to improve primary and community care so that people can stay healthy in their own home, and to address the long waiting lists. Under the programme, six new health regions have been established to provide integrated and timely care. The new Sláintecare programmes launched in 2025, aim for healthcare to be accessible, affordable and high-quality, and at minimal cost or free at the point of service (Department of Health, 2025).
Although Sláintecare aims to deliver quality care, the inherent hierarchical nature within health organizations in Ireland may impede timely care as hierarchy shapes how care is delivered, and impacts who receives care (Essex et al., 2023). Hierarchy can lead to insufficient and untimely care for the patients who need it the most due to a range of factors including delays in decision-making, communication, and collaboration among the various levels of staff. Around 70-80% of healthcare errors are caused due to poor communications between teams, and this impacts the delivery of care for patients (Essex et al., 2023).
Additionally, socioeconomic, and geographical factors add to healthcare inequalities. The report by Social Justice Ireland (2022) notes that the people who are poorest, sickest and with disabilities who are most in need – often wait the longest because they “find it hardest to pay charges, to negotiate access”. Also, for low-income families, it is a burden to cover healthcare and transport costs (Social Justice Ireland, 2022; 3). In sum, long waiting times in Ireland reflect both resource constraints (beds, staff, funding) and structural factors: two-tier access barriers and rigid organizational layers.
Delays in diagnosis and care can have serious consequences on patients’ health. There is a crucial need to understand all the causes (two-tier system, impact of hierarchy, and socioeconomic drivers) because the current reforms (e.g. Sláintecare) rely on improving coordination and efficiency. This paper examines the impact of hierarchy and the two tier system of healthcare in Ireland on the delivery of care. It highlights targets for intervention – such as clearing unnecessary management layers and providing equal access to healthcare– that could reduce wait-times and improve outcomes. Addressing these gaps aligns with the Health Service’s own goals: for example, improving access to health and social care services, improving service quality for patients and service users, and increasing capacity of the health and social care service.
Delays In Irish Healthcare
In 2022, Ireland was one of the countries ranked with the worst access to healthcare and with significant waiting times, with Ireland the only Western European country that does not offer universal coverage of primary care (see Social Justice Ireland, 2022 and (OECD/European Observatory on Health Systems and Policies, 2017). As a result, Irish hospitals operate at full capacity and have an acute shortage of beds resulting in delayed care. Ireland’s two-tier system allows private patients faster access to diagnostics and specialist care, while publicly-funded patients face long waits. The Irish Hospital Consultants Association (IHCA) confirms that more than 75,700 people have been added to diagnostic waiting lists over the past four years – an increase of 41% since the end of 2019 (Irish Hospital Consultants Association, 2024). The report on waiting lists published by the National Treatment Purchase Fund (NTPF) highlighted active waiting lists, with the number of people waiting for their first outpatient (OPD) appointments increasing from 523,225 in January 2019 to 629,919 in January 2021 (a 20% increase). Inpatient/day-case (IPDC) waiting times likewise increased from 129,243 to 146,680 in the same period. Intensive COVID-19 restrictions in 2020–21 pushed lists even higher. By the end of January 2022, active waiting lists stood at 731,800 total (OPD 625,513; IPDC 77,818; plus 28,466 awaiting gastrointestinal (GI) endoscopy) (Department of Health, 2022; 13).
In 2022, 2.6% of Ireland’s population experienced unmet medical care needs due to excessive costs, travel distance or waiting times (European Commission, 2023). This proportion was slightly higher than both the EU average (2.2%) and Ireland’s rate in 2019 (1.7%). Women reported a higher proportion of unmet healthcare needs, and excessively long waiting lists were by far their main driver for both genders (European Commission, 2023). The COVID-19 pandemic highlighted how healthcare services struggled and had to be provided with additional resources for timely care. It also highlighted shortcomings in the healthcare system across a range of areas and demonstrated how vital an integrated public system of care is, with healthcare workers central to the response to unprecedented health challenges (Social Justice Ireland, 2022). Before COVID-19, Irish hospitals ran at more than 95% occupancy, far above safe thresholds. Low bed capacity (2.9 beds per 1000 in 2019 – the third lowest in EU) meant any surge (e.g. a bad flu season or COVID wave) quickly created backlogs (OECD, 2021 cited in Social Justice Ireland, 2022).
As of January 2024, there were 679,247 patients on active waiting lists nationwide. Outpatient lists had fallen modestly (down 4% year-on-year) while inpatient/day-case lists increased by 3% (Department of Health, 2024). Despite the efforts of reducing waiting times for patients, only 35% of patients were within the Sláintecare time targets in late 2024 (Department of Health, 2024). Delays are not just administrative: they directly result in outcomes. Hospital consultants warn that pausing or rationing scans (such as CT, MRI, ultrasound) is risky: delayed radiology means cancers or strokes might be diagnosed much later, raising mortality levels (see O’Regan, 2025). The IHCA reports that nearly 80% of its annual diagnostics budget for 2024 was already used by February, forcing a temporary halt on new scan referral and the data also confirms that if there is a delay in scans for patients needing acute care, it could result in overcrowding in the emergency department (O’Regan, 2025).
Since the Sláintecare programmes have been implemented, there has been significant reduction in waiting lists for diagnosis and treatment, yet tens and thousands of people are still waiting for diagnosis and treatment. There have also been improvements in average waiting times, which have reduced by 1.6 months in 2024 in comparison with previous year (2023) (Department of Health, 2024). The new Sláintecare 2025+ plan was launched in May 2025, and it renewed Ireland’s commitment to universal, timely care (Department of Health, 2025). Minister Carroll MacNeill emphasized that “further reducing waiting times, targeting all patients to be seen within the Sláintecare targets of 10 and 12 weeks” is a central priority. The programme is backed by the largest-ever healthcare budget increase, aiming to expand infrastructure, digital tools, and community care (Department of Health, 2025).
Impact of Hierarchy
Beyond delay times, hierarchy within systems can also impact patient outcomes and result in slower care. Healthcare organizations traditionally have a steep hierarchy: decisions are taken by senior doctors and managers, often with many management layers between frontline staff and executives. This “pyramidal” structure is questioned by experts as hierarchical leadership with strict role definitions has been shown to create barriers in a crisis environment (Fernandopulle, 2021). Similarly, the hierarchy of healthcare in Ireland is hampering the overall system and impacting disease prevention, early diagnosis, and care. While GPs can refer both public and private patients for advanced diagnostics, specialist consultants then must approve tests or treatments, sometimes causing delays if clinicians are overloaded. Within hospitals, administrators oversee budgets and rostering, which can delay reallocating staff (e.g. for extra clinic sessions or weekends). At the system level, the HSE’s multi-layered bureaucracy (national and regional management) is known for slow reform processes (Schulmann et al., 2024). By contrast, flatter systems result in local units having more autonomy, enabling quicker hires or conscious use of resources. The scoping review found that hierarchical culture can discourage staff from speaking up about problems, reducing innovation and safety. Nurses and junior doctors in Ireland frequently report feeling unable to question senior decisions, indicating a rigidity that could indirectly prolong waits (e.g. not challenging a consultant’s long clinic waitlist) (Fernandopulle, 2021, see also Essex et al., 2023).
Countries that have moved towards a flatter model of healthcare have lower levels of delays and manage patient flow more efficiently. The American Nurses’ Association (ANA) recently found that a few hospitals working with a flattened healthcare model had smooth functioning, good work environment and easy staff retention and recruitment process (Fernandopulle, 2021). In addition, direct channels of communication, assigning more diagnostics to radiographers early on, or giving GPs limited direct access to imaging (as is done in some regions), can cut steps in the referral chain. Moreover, making specialists accessible early on can also result in better care delivery. In conclusion, while not the only cause of delays, Ireland’s steep administrative and clinical hierarchies accentuate wait-times by slowing decision-making and care delivery.
Private and Public Healthcare
Ireland’s two-tier nature means that public and private patients experience very different waiting times. While private healthcare is expensive, those who pay with insurance enjoy quicker access to specialists and diagnosis. The private wards are less overcrowded and private patients routinely meet target times: the insurance market effectively guarantees a 0–3 month wait (depending on policy) via in-network clinics.
In contrast, public patients (those without insurance or not opting for private services) face long queues. Evidence shows median waiting times differ dramatically by insurance status: one analysis found that uninsured patients often wait longer for elective procedures like hip replacements and diagnostic tests than insured ones, and, as a result of this, the number of people opting for insurance has increased (Donnellan, 2024). Previous studies have also recorded that patients in the public healthcare system might wait more than 22 weeks for an MRI and 55 weeks for a CT scan with a GP’s referral, compared to a privately insured patient who might get such scans in 5 weeks and 6 days respectively (Bowers, 2025, see also Cornmarket Group Financial Services Ltd., 2018). In short, insurance status is a strong predictor of wait-time in Ireland: “those who can afford insurance are treated quickly while those who don’t have to face long waits” (Donnellan, 2024; para 3).
Comparative studies find that two-tier countries like Ireland typically have longer public waits for similar procedures than single-tier countries. For instance, in a 2020 OECD report, it noted that adding private capacity without integration often just shifts wait-times from private to public lists. Countries like Denmark, Portugal and Finland avoided and reduced the wait times by guaranteeing maximum waits to all, regardless of insurance status. These countries have also introduced fast track pathways for cancer patients, sometimes facilitated by additional dedicated funding and capacity (OECD, 2020).
Impact on Patients
Long delays in diagnosis and treatment impose heavy costs on patients, families, and the health system. Delays in essential tests like imaging, biopsies and endoscopies can worsen outcomes especially in cancer and cardiology. For example, the IHCA (2024) reports that delaying CT/MRI scans is “especially concerning” as these are needed to confirm or rule out serious conditions like cancer; one-eighth of Irish patients reportedly wait over a year for key scans (O’Loughlin, 2025). In 2022, cancer was the leading cause of death in Ireland, accounting for nearly three in every ten fatalities (OECD, 2023). Late diagnoses mean disease progression, requiring more aggressive therapies (often with higher risk) and reducing survival chances. Studies link longer wait-times to stress, lost work productivity, complications (e.g. diabetic damage from postponed checkups, loss of life due to delayed cancer diagnosis and treatment), and even loss of patient trust (Impact of Treatment Delay on Health Outcomes, 2025, see Badrie, 2025). Financial, emotional and social burdens arise from rescheduled appointments and missed work. Delays also increase system costs by pushing avoidable complications into emergency care and intensive treatment (IHCA, 2024, O’Loughlin, 2025). Overcrowding and delays can also degrade patient dignity and safety.
Policy Recommendations
Extend the Capacity: The urgent priority is reducing waiting times as mentioned in the Sláintecare 2025 Programme report (Department of Health, 2025). This requires a temporary surge in capacity (extended hours, weekend clinics, outsourcing) combined with more funding for scans and surgeries. For example, Denmark and Finland achieved notable wait reductions by guaranteeing maximum waits and quickly referring overflow cases to alternate providers. There needs to be a focus on increasing capacity, reforming scheduled care, and the use of enabling technologies to reduce waiting lists and waiting times. There is also a need to improve the built healthcare infrastructure and reduce regional disparities.
Invest and provide funding for primary care: Delays at the hospital door often begin with bottlenecks in primary care. Expanding free GP care to all residents (as Sláintecare aims) would remove the €50 barrier that deters early consults. While immediate fixes are needed, long-term financing reforms are also crucial. Ireland’s health spending (~7% of GDP, 11.4% of Gross National Income (GNI)) is high relative to outcomes. Reallocating funds toward value (more care in community, less in expensive hospitals) could improve access.
Flatten Hierarchies: Organizational reform is needed. Hospitals should adopt more flexible management structures – for example, giving department heads the authority to reallocate slots or staff to ease bottlenecks without waiting for central approval. Encouraging a “flat hierarchy” culture (where nurses and junior doctors can flag bottlenecks) can identify systemic delays sooner. There is also a need for patients to have access to specialists sooner instead of only their GP. Leadership training should also emphasize multidisciplinary teamwork and shared governance.
Recruiting workforce: Persistent staffing shortages underlie many delays. There is a need to accelerate recruitment (e.g. streamlined international hiring) and improve retention (competitive pay, career supports) especially in high-demand roles like GPs, radiologists and specialists, as noted by Sláintecare as well.
Implement Sláintecare fully: Full focus should be in implementing Sláintecare and achieving its goals of increasing access to health and social care services, improving service quality for patients and service users, and increasing capacity of the health and social care system. Effective governance and committed senior leadership are critical to achieving successful outcomes in implementation.
Conclusion
Ireland’s healthcare system needs a systemic reform to function at its finest. Even if there have been some improvements after the Sláintecare Programme, waits, delays and hierarchy still result in unequal access to care. Progress of Sláintecare has been slow. To fix this, Ireland needs to increase hospital and community care capacity, hire more staff, make it easier to get GP appointments, and simplify the way that decisions are made in healthcare settings. Most importantly, the government needs to fully commit to Sláintecare and make healthcare fair, timely and accessible to everyone, no matter their income or where they live. In doing so, this upholds the basic human right to healthcare.
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