Albert Dolan: Questions over NTPF reliance, SLAs and hospital deficits
Albert Dolan questions hospital management and finance officers about growing reliance on NTPF insourcing funds, delayed service level agreements and mounting deficits during a committee session. He probes how insourcing receipts rose from 929,000 to 11.4m between 2020 and 2025, the use of side letters and potential governance risks.
Albert Dolan pushes for clarity on the process used to identify conflicts of interest in NTPF-funded activity and asks why insourcing has become a significant funding stream for the hospital. He highlights the scale of the change in insourcing receipts and asks whether the organisation is now dependent on that funding.
Hospital leaders told the committee that NTPF-funded insourcing removed almost 14,000 patients from waiting lists last year across 17 specialties. The witnesses say without that additional capacity the hospital would face an immediate loss and underused infrastructure, illustrating the real patient-level impact of ad hoc funding.
Dolan scrutinises the timing of service level agreements, noting many SLAs are signed late in the year and are accompanied by side letters acknowledging expected additional costs such as winter surge activity. He presses officials on how payments are drawn when a signed SLA is not yet in place and flags auditors warnings about accumulated deficits and potential governance risk.
Hospital officers describe tight controls over non-pay spending and monthly management accounts, but point to rising pay and medication costs as driving pressure. The officials advocate multi-annual, activity-based funding models and improved collaboration with the HSE to avoid repeated year-end shortfalls and last-minute side letters.
Key questions on funding and process
Albert Dolan pushes for clarity on the process used to identify conflicts of interest in NTPF-funded activity and asks why insourcing has become a significant funding stream for the hospital. He highlights the scale of the change in insourcing receipts and asks whether the organisation is now dependent on that funding.
Insourcing impact on patients and capacity
Hospital leaders told the committee that NTPF-funded insourcing removed almost 14,000 patients from waiting lists last year across 17 specialties. The witnesses say without that additional capacity the hospital would face an immediate loss and underused infrastructure, illustrating the real patient-level impact of ad hoc funding.
SLA timing and governance concerns
Dolan scrutinises the timing of service level agreements, noting many SLAs are signed late in the year and are accompanied by side letters acknowledging expected additional costs such as winter surge activity. He presses officials on how payments are drawn when a signed SLA is not yet in place and flags auditors warnings about accumulated deficits and potential governance risk.
Costs, controls and the case for reform
Hospital officers describe tight controls over non-pay spending and monthly management accounts, but point to rising pay and medication costs as driving pressure. The officials advocate multi-annual, activity-based funding models and improved collaboration with the HSE to avoid repeated year-end shortfalls and last-minute side letters.
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Transcript
I just want to start out with the matter firstly and primarily just I guess in your opening statement and in the briefing we received it asserted that quote no conflicts of interest have been identified involving any grade of staff and so that's obviously in relation to NTPF funded activity. What process did you use to identify whether there was or wasn't conflicts? Because we weren't bringing in any companies for any insourcing, we weren't bringing in any third party vendors so there was no conflict because we were bringing in staff that were being employed as nurses or doctors and that was their primary purpose so they were coming in as a full contract of 35 or 37 hours to deliver NTPF. Okay and so those staff they weren't, how do I say it, they weren't matter staff were they? No they would have been additional staff. Additional staff brought into the matter though? Brought into the matter to deliver NTPF. Okay. But very clearly identified as NTPF staff. Okay and just the reason I ask that is because from 2020 to 2025 per page 8 of the briefing the insourcing receipts grew from 929,000 to 11.4 million euros. So in the space of five years this has obviously become a significant method of funds for yourselves. Do you find that you're now dependent on insourcing funding? For sure we are but I'm actually going to get my COO to give you a better overview if that's okay. So as you mentioned Deputy our reliance or our capacity to use NTPF funding has increased incrementally over the years to the point now where we saw almost 14,000 patients off the waiting list last year with it. That has been identified activity across 17 different specialities and without it we would have those 14,000 patients from last year and indeed all the patients the year before on our waiting list because they are providing extra and additional capacity. Without it we would be at a significant loss and we would be then in the position where we would empty infrastructure unused in the organisation. Okay so say all of your funding is agreed with the HSE based on a service level agreement is that correct? Correct. Okay and do you run a deficit on that or is it ever the case that the funding is insufficient? So I might get our Chief Financial Officer to answer that. I think it's fair to say that generally it would be insufficient so we do look and see that it is a case of underfunding. I know as we've said already here today in 2025 the hospital achieved a break-even position but if we go back further one more year to 2024 we were left with a deficit for that year in isolation of 18.7 million as a result of underfunding. And so the reason I ask about this is because you're given a service level agreement, you sign it. Subsequent to you agreeing what's in that service level agreement, the amount of funding and the levels of service that are expected to be delivered under that, do you subsequently send a side letter to the HSE saying this isn't enough? How quickly after signing the service level agreement are you going back to the HSE saying oh yeah just to let you know we signed this document yesterday but today now it's not sufficient? So the ideal model would be that we would have a service level agreement that we would know in January what our funding allocation is, what the activity is expected to be delivered and then as you will go through the year deputy if you saw you were actually going above there should be a process to go back to say we're actually going to go above this that is going to incur an extra cost. That process doesn't occur at the minute. So do negotiations take place as in at the start of the year you have a clear expectation of what your service levels are going to be, you set that out with the HSE, service level agreement is signed but then how quickly after are you coming back to the HSE saying we're going to run way over here? Because my fear is and I understand you have to keep your doors open, you have to make sure the patients get seen and offer an incredible service which I appreciate you do but is it a case of a blank check here? Can you just keep going back every time? No so I suppose for us the frustrating part is and this is why I say there needs to be reform in relation to the process. We need to be involved and we are starting to work collaboratively with the HSE. We can forecast based on our activity, our pay, our non-pay what we would require to run the hospital for the next year but what happens is we get an allocation that's quite significantly lower than that so this is where the SLA tobacco where we're seen to be delaying sign the SLA but we can sign an SLA if we know we don't have the funding to deliver what we need to deliver and this is where we need to be looking at and that's why I go back to the multi-annual activity based funding that model would allow. Can I just ask then lastly just on that topic do you send a side letter afterwards saying it's not enough? We send a side letter with SLA's because we've signed our last SLA last year it was in November which is farcical because you're signing at the end of the year for the year you're just delivering. Of course. You're always saying as part of the side letter that there needs to be an acknowledgement of how you would factor in in-cuse activity be it winter surge or other planned activity so we always would have a side letter that would go in. So a side letter goes but how quickly after signing does the side letter go? It goes with the signed we always send a side letter with our signed SLA because we're at the end of the year. Okay I just I think that's definitely something that needs to be looked at is you know if you're going the whole year without signing your service level agreement as a section 38 I don't know if that runs a risk like how are you able to draw down payments throughout the year if you don't have a service level agreement in place with HSE? So I might get my financial officers come in on that but just to say I totally agree I would love to have my service level agreement signed in January for this year and then be able to financially plan and look at activity like openly and transparently whereas we're actually it's really it's too late in the year when you're signing an SLA and it's not so this is where we need to be involved we need to have collaboration with the HSE looking Is there anyone from the HSE here? How many hospitals only sign their SLA agreements by the end of the year? Well they would all be expected to actually sign their service agreement you mean later in the year it came to the matter? Well like I'm saying obviously if an agreement is going to be made about how much money is going to be budgeted for 2026 I'd assume all of those documents should be well signed by now we're in April so are there many hospitals that are outstanding signatures at the moment on SLAs? Well the most significant in our region and I can only speak to our region Deputy would be the matter in that context. So the matter is the only one that hasn't? No not the only one but in terms of value so we'd have a value of about two billion worth of service arrangements yeah we've about 1.2 billion signed so the matter is about 600 million so that would bring us up to a value of about 1.8 billion. So can I ask what's holding the matter back from signing an agreement with the HSE right now given that we're in April and you're basically saying to me that you probably won't sign this till December because you'll have to and I want an answer from the CFO as well just how do you draw down payments from the HSE when there's no agreement in place like that has to be a huge governance risk for both the HSE, the state and your own hospital you're you're drawing down payments with no underlying agreement? Absolutely so I'll get Adam to answer that for you Deputy. So in terms of the payments that we draw down we're given a cash profile from the HSE for the year so they based that on the current budget that we've been allocated so for 2026 for example we currently have an allocation of 597.2 million but just for context for the committee we finished out 2025 with a final allocation of 614.8 million so we're effectively 17 million behind our final position for last year before we factor in any of the additional payments such as 15 million for pay awards under the national agreements for 2026. Just on the private auditors had warned hospital directors the accumulated deficits were so large that they were at risk of trading recklessly under company law. How do you manage that and I mean like that's a fairly that's very hard-hitting statement from the auditor to suggest that people could be trading recklessly under company law and I don't think auditors would say that lightly so I'm just asking you know how are you managing your budgets that you're ending up in such deficits? I understand you're delivering a massive service and it has to be funded but I guess it's quite shocking that there's no SLA in place to underpin all of this activity even to allow you some head room for overrun. So I think like when I go back to last year with the risk-sharing agreement we absolutely broke even because we sat in a room, we identified what we needed, we sat with the HSE, they identified areas they hadn't spent. We cannot build on the 48.7 million deficit that's there so what we wanted this year was a hope that we would start off with what we have forecast as a budget that there would be discussions of how we would get as near to that and then what we would have to do is map our service accordingly with that so we want to absolutely get the SLA signed. Just last question because I'm conscious of the time. How are you managing your costs? Like just are your costs getting out of control and is there waste in the hospital? No so I suppose just to reassure we have management accounts for every director within the hospital so whether it's surgery, ED, we can look at both pay and non-pay, we view that on a monthly basis, we see where the trends are. A lot of our funding is actually fixed and outside our remit because it's pay so we look at what we can manage. Our non-pay is quite tight, we absolutely have very tight process, we go through the frameworks that we can in relation to non-pay so we don't feel there's a lot of meat left on the bone in relation to non-pay but just to put in context our medications went from 42 million in 2019, we're now spending 82 million a year on medications alone and if you put an implantable device into somebody's heart that has actually gone up 43% on non-pay cost with inflationary costs so but we do to reassure the committee we absolutely scrutinize our pay and non-pay. Thanks Deborah.