Senior management in the health service had anticipated that restricting the use of the practice known as insourcing to tackle hospital waiting lists would likely result in reduced access to care for some patients.The HSE leadership last year believed controls introduced at the time on insourcing would have “some impact” and that about 4 per cent of patients who received treatment under such arrangements could be affected. However, the warnings in the confidential internal report from the HSE in the West and North West region – that the complete ending of insourcing would lead to a rapid growth in waiting lists, affecting many thousands of patients – are much more stark.Insourcing involved external companies or other third parties using public hospital staff or facilities to treat patients outside of normal working hours. The practice fell within official Government policy, under which large sums of money – €1.23 billion between 2022 and 2024 – were allocated either to the HSE or the National Treatment Purchase Fund to drive down waiting lists.However, the insourcing funding facilitated the development of a multimillion-euro private industry within the country’s public hospitals.For decades hospitals had offered regular overtime to staff, but third-party insourcing was different. It involved external companies putting together teams of doctors and other staff who were paid premium rates to carry out additional work outside of core hours. The system proved successful in that more patients on waiting lists were treated. But it was also highly lucrative for those involved.Exactly a year ago, a HSE report to the Oireachtas revealed that over a 27-month period to March 2025, three companies had between them received more than €70 million. One, EHF 29 Limited, received €54.636 million. Accounts for 2023 show that EHF 29 Limited had recorded an annual profit of €2.39 million.Another company, Rosata Recruitment, received €10.3 million in the 27 months to March 2025.But behind the scenes there were concerns about potential conflicts of interest, perverse incentives, and governance and oversight shortcomings.[ A close look at one of the new surgical hubs in Ireland: ‘Low complexity, high volume’Opens in new window ]CHI, the group that operates children’s hospitals in Dublin, told The Irish Times last year that it had raised concerns regarding insourcing and the potential conflict of interest for staff with the HSE on several occasions, including at a meeting in 2023.In June last year, then HSE chief Bernard Gloster said the health system had become too dependent on third-party insourcing. A series of controversies had resulted in the practice being stopped in a number of hospitals, including Beaumont and Naas. Gloster put restrictions in place on the use of insourcing with a view to phasing it out completely by the end of June 2026. The HSE told The Irish Times on June 30th that no new third-party insourcing initiatives, extensions or additional arrangements were to start after that date.While the HSE central leadership last year considered the health service too dependent on third-party insourcing, the position of its regional chief in the West/North West, Tony Canavan, in a 12-page memo dated April 20th, was significantly more forthright.“The planned cessation of third-party insourcing by 30th June 2026 will have an immediate and material impact on service delivery across the HSE West North West region. Insourcing is embedded within core operational delivery, providing critical additional capacity to manage demand and provide essential care across outpatient, inpatient day case and gastrointestinal scope waiting lists and services since its introduction in January 2022,” the memo stated.