The healthcare economyi General
Most medical treatment is available free of charge or subject to a subsidised charge under the public health system. There are two types of patient in the public healthcare system: (1) individuals with full eligibility ('medical card holders' or 'public patients'), who are entitled to receive all health services free of charge; and (2) individuals with limited eligibility ('non-medical cardholders' or 'private patients'), who are entitled to some free or subsidised services. Eligibility for a medical card is dependent upon income and is decided on the basis of a means test.
Access to public and private healthcare within this jurisdiction varies for people based on their citizen or non-citizen status. If a person is a national of the European Economic Area (EEA) or Switzerland, or he or she is ordinarily resident in Ireland (i.e., living in Ireland for at least one year), he or she is entitled to receive the same level of healthcare as Irish citizens. If a person is not from an EEA Member State or Switzerland, he or she will only be entitled to certain services free of charge and will have to pay for the remainder. If a person opts for private healthcare services, he or she must pay the full costs of treatment, unless those costs are covered by that person's private health insurance policy.ii The role of health insurance
There are a number of private health insurance companies in Ireland. Key providers include VHI Healthcare, Laya Healthcare and Irish Life. As long as an individual is from the EEA or Switzerland, or ordinarily resident in Ireland, he or she is entitled to the same benefits from private health insurance with any of these companies as any other Irish citizen.
Health insurance is not mandatory. However, the most recent statistics indicate that approximately 46 per cent of the Irish population holds private health insurance, a key benefit of which is avoiding public waiting lists for elective procedures.
Private health insurers are regulated by a statutory regulator, the Health Insurance Authority, and under the Health Insurance Acts 1994–2018. The principal objective of the Health Insurance Authority is to ensure that access to health insurance cover is available to consumers of health services with no differentiation made between them.iii Funding and payment for specific services
The Irish healthcare system is primarily funded by taxation, with contributions from out-of-pocket payments and voluntary private health insurance. As in other countries, revenue from general taxation in Ireland is, of course, not designated specifically for the healthcare economy. Therefore, this sector must compete with other areas of public expenditure for attention as far as funding through taxation is concerned.
Holders of a state medical card (i.e., public patients) are entitled to receive all health services free of charge, including GP services, prescribed medicines, all dental, ophthalmic and aural services, maternity services, inpatient services in public hospitals and specialist treatment in outpatient clinics of public hospitals.
The majority of the population does not hold medical cards (i.e., private patients) but they are still entitled to free maternity services, inpatient services in public hospitals (subject to a daily charge), specialist services in outpatient clinics (subject to a daily charge), assistance towards the cost of prescribed medicines over a monthly limit (€124) (under the Drugs Payment Scheme) and assistance towards the cost of prescribed medicines for certain chronic conditions (under the Long-Term Illness Scheme) or high-cost treatments (under the High-Tech Drug Scheme). They must, however, pay for all GP consultations and all dental, ophthalmic and aural treatments.
Children in Ireland have the same entitlement to health services as their parents. This means that if a child's parents have a medical card, they too are included as a dependant on that card and are entitled to the same range of services as their parents.
Additionally, there is a range of healthcare services available specifically for children. A number of these services are provided free of charge for children even if their parents do not have a medical card. These services are generally provided as part of maternity and infant welfare services, health services for preschool children and school health services. Children are also entitled to vaccination and immunisation services free of charge.
A GP visit card is available to all children under the age of six. This allows free GP care for all children under the age of six. For other children, the GP visit card is means-tested. The HSE is obliged to provide dental services free of charge to preschool children and school children attending state primary schools referred from child health service and school health service examinations. Dental services for children under 16 years of age who attend state primary schools, and are referred from child and school health services, are provided in HSE clinics and primary schools.
Primary / family medicine, hospitals and social carei The scope and role of practice of corporate and professional health and social care providers
Healthcare is mainly delivered by way of primary or secondary care. Primary healthcare services are provided outside hospitals to people living in the community; for example, by general practitioners, nurses and health clinics. Secondary healthcare is delivered in hospitals to patients normally living at home; for example, outpatient clinics, and accident and emergency clinics.Doctors
The Medical Practitioners Act 2007 (as amended) regulates the medical profession in Ireland. It provides for the registration and control of medical practitioners, outlines the membership and functions of the Irish Medical Council (IMC) and obligates the IMC to establish various committees to consider complaints made against practitioners. Under the Medical Practitioners Act 2007, an unregistered medical practitioner is not permitted to practise medicine in the state. Registration is on an annual basis.
The main functions of the IMC are to:
- maintain a register of doctors;
- ensure high standards of medical education and training;
- specify standards of practice for doctors, including the areas of professional competence and ethics;
- provide guidance to doctors on compliance with standards of practice;
- promote good medical practice;
- investigate complaints made about doctors and, where necessary, conduct disciplinary procedures. The IMC has the power to suspend, attach conditions to registration or erase a doctor's name from the register; and
- advise the Minister for Health on matters relating to doctors and patient safety.
The Nurses and Midwives Act 2011 regulates nurses and midwives in Ireland and requires all nurses and midwives working in Ireland to register with the Nursing and Midwifery Board of Ireland (NMBI). The NMBI's main functions are to:
- establish procedures and criteria for the assessment and registration of nurses and midwives;
- act as the competent authority for the mutual recognition of professional qualifications of nurses and midwives awarded in or recognised by EU Member States;
- specify standards of practice for registered nurses and midwives;
- specify criteria for specialist nursing and midwifery posts;
- establish committees to inquire into complaints; and
- make decisions and give directions relating to the imposition of sanctions on registered nurses and registered midwives.
The dental profession in Ireland is regulated by the Dental Council of Ireland (DCI) and only dentists registered with the DCI can practise dentistry in Ireland. The DCI was established under the provisions of the Dentists Act 1985 and its main functions are to:
- establish, maintain and publish a Register of Dentists, Dental Specialists, Dental Hygienists and Dental Nurses;
- regulate the dental education and training provided in Irish dental schools and to set standards required for primary qualifications;
- inquire into the fitness of a dentist to practise dentistry and investigate any alleged professional misconduct. The Council has the power to suspend, attach conditions to registration or erase a dentist's name from the Register;
- make, with approval of the Minister for Health, schemes for the establishment of classes of auxiliary dental workers; and
- advise the dental profession and the public on all matters relating to dental ethics and professional behaviour.
The Health and Social Care Professionals Council (CORU) is an independent regulator established to promote high standards of professional conduct and professional education, training and competence among registrants of health and social care professions.
CORU currently maintains registers for dieticians, occupational therapists, radiographers and radiation therapists, social workers, speech and language therapists, optometrists and dispensing opticians, physiotherapists, medical scientists, podiatrists, psychologists and social care workers.
Members of these professions are required to register with CORU in their respective professional registers and only members registered with CORU can legally use the title of those professions.
CORU also handles complaints about the fitness to practise of registered health and social care professionals. This may include, for example, complaints of professional misconduct or poor professional performance.ii Direct access to medical consultants
GPs supervise and guide the overall health management of their patients in Ireland and facilitate referrals for secondary care in accordance with IMC guidelines. Hospital consultants will see patients following referral from their GP or other treating doctor.
When a patient is admitted to hospital, either in an emergency or on a planned or elective basis, they will be under the care of the admitting consultant.iii Universal electronic medical records
Universal medical records do not currently exist in Ireland. The current state of health records in Ireland is one of largely paper-based patient notes, held within individual organisations.
Over the next 10 to 15 years the HSE plans to roll out a national Electronic Health Record (EHR) that will enable patient information to be instantly accessed by approved medical personnel. The establishment of a national EHR has been identified as a key capability requirement for the future delivery of healthcare. The project is being overseen by eHealth Ireland, a dedicated entity tasked with using information and communication.iv Data protection laws
The sharing of patient data is governed by Data Protection Acts 1988 and 2003 (DPA), under which personal data must be obtained for a specified purpose, and must not be disclosed to any third party except in a manner compatible with that purpose. Under the DPA, there are a number of limited bases on which health data may be disclosed, including where the patient has explicitly consented.
If patient data is urgently needed to prevent injury or other damage to the health of a person, then a medical professional may disclose the data. However, if the reason for the disclosure is not urgent, then consent of the patient should be obtained in advance.
Patient data can be disclosed for research or other statistical purposes without the patient's consent in limited circumstances. However, anonymisation or pseudonymisation should first be considered where patient data is disclosed for research purposes.
The General Data Protection Regulation (GDPR) came into effect on 25 May 2018. The GDPR has 'direct effect' and therefore it does not require transposition into Irish law for organisations to become amenable to its provisions. The GDPR enhances transparency, security and accountability by data controllers and processors. It requires that personal data shall be obtained only for specified, explicit and lawful purposes and shall not be further processed in any manner incompatible with those purposes. Personal data shall be relevant and limited to what is necessary in relation to the purposes for which they are processed. Personal data shall not be kept for longer than is necessary for the purposes for which the personal data are processed. Personal data can be lawfully processed for the purpose of preventative or occupational medicine, assessing a person's working capacity, for medical diagnosis, for the provision of medical care, treatment and social care, for the management of health or social care systems and services, or pursuant to a contact with a health professional. The HSE's current policy is to delete a patient's medical records after seven years; however, data may be held for a longer period if this is in the patient's best interests. The HSE is in the process of developing a national data protection office and is to appoint an Independent Data Protection Officer to advise the HSE on its data protection processes.v The IMC Ethical Guidelines
In accordance with the IMC Ethical Guidelines, a doctor can share information with other doctors in appropriate circumstances without the patient's consent (e.g., the patient cannot give consent because of his or her medical condition). If disclosure of a patient's information is necessary as part of the care and treatment of the patient, the Ethical Guidelines permit disclosure to the appropriate person on the basis that they understand that the information is confidential.
The Ethical Guidelines state that where a patient is capable of making his or her own decisions about his or her healthcare, a doctor must first obtain patient consent before disclosing information that identifies him or her. If a patient lacks capacity to consent and is unlikely to regain capacity, the Ethical Guidelines state that a disclosure may be made if it is in the patient's best interests.