The quiet revolution in Irish healthcare

Across advanced economies, healthcare is caught in a pincer movement: ageing populations swell demand just as staffing shortages constrain supply. Waiting lists lengthen, budgets creak, and voters grow impatient. Ireland faces the same structural headwinds as everyone else. Yet, look closely, and you’ll see a series of decisions—some technocratic, some boldly political—that are gradually redirecting the system toward universal, affordable, and earlier care. The payoff is not cinematic; it’s cumulative. And relative to many countries still debating first principles, Ireland has begun to execute.

Terence Cosgrave

The centrepiece is a multi‑year roadmap for universal, timely care—Sláintecare’s next phase—paired with concrete delivery vehicles: elective surgical hubs, community‑based capacity, and specific targets on access. This matters because health reform so often stalls on the rocks of vagueness. By contrast, Ireland’s approach is boring in the best way: it sequences capacity (new surgical and diagnostic slots), rewires referral pathways, and tracks waiting times. It’s industrial policy for healthcare: build the plant first, then promise shorter queues. Countries that skip the build phase end up rationing by frustration. Ireland is trying to ration less by building more.

Universal rhetoric doesn’t pay the patient’s bill; policy does. Two moves stand out. First, the abolition of public in‑patient hospital charges removed a lingering toll on illness. Second, the steady widening of free GP care—now covering a large minority of the population—makes first‑contact medicine more like a public utility and less like a discretionary purchase. Internationally, these are not small things. Many wealthy systems still rely on co‑pays that nudge people to delay care until conditions worsen. (Don’t get me started on America!) Lowering the financial ‘activation energy’ to seek help doesn’t just feel fair; it is economically efficient. Earlier care is cheaper care.

Capacity isn’t only about beds and theatres; it’s also about time. The decision to let GPs directly order community‑based imaging—X‑ray, CT, MRI, DXA, and ultrasound for many patients—compresses the diagnostic cycle from weeks to days. The result is fewer unnecessary hospital referrals and quicker clinical decisions.

Economists would call this a reduction in transaction costs; clinicians would call it common sense and ‘about time’. Either way, it tilts the system toward speed. Many peer countries talk about ‘shifting left’ into primary care; Ireland is operationalising the cliché by moving diagnostics down the street from the hospital. That helps patients, and frees hospitals to do what only hospitals can do.

A striking feature of Ireland’s recent trajectory is how women’s health has been mainstreamed into system design. Free prescription contraception for younger and now mid‑thirties cohorts, menopause services that are defined rather than aspirational, and rapid ‘see‑and‑treat’ gynaecology clinics together send a signal: preventive and life‑course care is not peripheral.

Compare this with countries that still treat contraception as a pocketbook issue or menopause as an afterthought. The benefits are immediate (fewer cost barriers) and long‑term (better population health). Crucially, these are the kinds of services that reduce emergency spikes three years from now—the sort of quiet dividend maniacal reformers, such as myself, love.

Assisted human reproduction has historically been a wallet test in many systems. Ireland’s roll‑out of publicly funded fertility services, including a defined IVF entitlement for eligible patients and a broadening of access criteria, shifts that burden from household to health service. The comparative edge here is real: even among high‑income countries, coverage is patchy, means‑tested in opaque ways, or limited to partial reimbursement.

Bringing affordable human reproduction into the public tent is equity policy, yes, but also demographic policy: making family formation less hostage to savings accounts. As with women’s health more broadly, the message is that reproductive health is part of health, full stop.

National electronic health records (EHR) and interoperable data rarely trend on social media, but they are the connective tissue of modern care. Ireland’s recent steps toward a national EHR—focused on integration across settings—are the sort of infrastructural bet that pays out in safety (fewer errors), access (patients can actually see their information), and productivity (clinicians spend less time hunting data). In economics terms, this is platform investment: expensive up front, deflationary over time. Countries stuck in pilot‑land will find it harder to unlock the same compounding benefits.

If you zoom out, the common thread in these reforms is front‑loading value. Abolish small but pernicious charges, expand GP access, bring diagnostics closer, and hard‑wire services for women and fertility—all the while building elective capacity and digital rails. Each move chips away at the two great distortions of healthcare: delayed care and misallocated time.

That’s why this country’s strategy is not just morally appealing but also economically rational. Marginal care delivered early is cheaper than marginal care delivered late. And an hour of a consultant surgeon’s time spent operating, rather than triaging avoidable referrals, produces more health per euro.

Workforce remains the binding constraint. Expanding entitlements without expanding clinicians is a recipe for frustration. Ireland will need to train, recruit, and retain aggressively—especially in general practice, nursing, and diagnostics. Infrastructure projects must land on time; capital budgets are not magic. And reform is not linear: political cycles, cost overruns, and outside shocks (pandemics?) can derail momentum. But these caveats are not arguments against the direction of travel; they are reasons to stay the course. The biggest risk now is policy whiplash—oscillation that kills compounding benefits.

Plenty of countries have elegant white papers. Fewer have turned bullet points into booked appointments. Ireland’s comparative advantage right now is pragmatic execution. Absent an NHS‑style behemoth to overhaul, the Irish state has been able to iterate—test surgical hubs, scale community diagnostics, ratchet eligibility, and watch the numbers. That nimbleness—call it small‑country industrial policy for health—can be a superpower. And because the moves target the system’s conversion funnel (from first contact to diagnosis to treatment), the benefits show up where voters live: fewer bills, quicker answers, shorter waits.

Healthcare progress is a bit like climate mitigation: the most important victories are invisible. A cancer found this month rather than next year; a surgery scheduled in weeks rather than seasons; a couple starting IVF without a second mortgage. None of these stories scream ‘reform’, but add them up and you get a healthier, fairer society—and a system that costs less than it otherwise would. Ireland hasn’t solved healthcare. No one has. But in a world of chronic under‑delivery, it’s moving in the right direction, and doing so in ways that other countries can copy without importing culture wars. That’s a revolution worth rooting for—even if it arrives, as most good things do, quietly.

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In this bright future, we can’t forget our past. We are reminded again this week that the State has continued to fail to close the book on the Irish Thalidomide scandal.

Thalidomide, a drug heavily marketed as ‘safe as a sweet’ for morning sickness, was later proven to cause devastating birth defects. Damage caused by thalidomide included catastrophic disabilities to arms and legs, missing limbs, internal damage and hearing loss. Globally, an estimated 90,000 pregnancies ended in miscarriage or stillbirth. Of the 10,000 children born alive, half died at birth or within their first year. (I’ve written about this previously here.)

Today, around 40 Irish survivors remain, now all in their 60’s and dealing with the pain and life challenges caused by the overuse and misuse of malformed limbs. The numbers continue to dwindle as members die. And still, the State report on infant deaths caused by thalidomide in the early 60’s has never been published.

Although the drug was withdrawn internationally in November 1961, The Irish state deliberately chose not to conduct a complete withdrawal, nor did they warn the public. As a result, thalidomide products remained in medicine cabinets in homes, and even on pharmacy shelves, for years.

Now we discover that the responsible technical officer overseeing production at Chemie Grünenthal – the company that produced thalidomide – was a Dr Heinrich Mückter, who was also responsible for the development of thalidomide at that firm. Mückter was implicated in human experiments in Nazi concentration camps during World War II, later served as Grünenthal’s head scientist. Documents from the Department of Health in the National Archives show that over several years, when requested by the Department of Health, Mückter personally signed statements confirming he was the responsible technical officer overseeing production at Chemie Grünenthal.

We can’t really build a quiet revolution in the future without dealing properly and comprehensively with the past. And yet, thalidomide and World War II still cast a shadow.

It’s time to close that particular book and move on to a better future. We can’t do that without being fair to the past, remembering the thalidomide victims, and making things right with them while we still can.