Hundreds of Irish Patients Use Cross-Border Healthcare Schemes to Bypass HSE Waiting Lists as System Strain Deepens

Hundreds of Irish Patients Use Cross-Border Healthcare Schemes to Bypass HSE Waiting Lists as System Strain Deepens

Hundreds of Irish patients are availing of EU and bilateral cross-border healthcare schemes to bypass long HSE waiting lists, with 232 patients from County Mayo alone using the schemes between 2024 and 2025, and private facilities in Northern Ireland such as Kingsbridge Hospital treating thousands of patients from the Republic — but the schemes' reimbursement model, which requires patients to pay upfront, is raising serious equity concerns about access for lower-income patients.

Background

The concept of cross-border healthcare within the European Union has been a feature of EU policy since the adoption of the Cross-Border Healthcare Directive in 2011. The directive gives EU citizens the right to seek healthcare in any EU or EEA member state and to be reimbursed for the cost of that treatment by their home country's health system, up to the amount that the treatment would have cost at home. For Irish patients, this means the right to seek treatment in any EU country and to claim reimbursement from the HSE.

In addition to the EU directive, Ireland has a bilateral arrangement with Northern Ireland — the Northern Ireland Planned Healthcare Scheme — that allows patients from the Republic to access private treatment in Northern Ireland and to claim reimbursement from the HSE. This scheme is particularly significant given the geographic proximity of Northern Ireland and the Republic, and the fact that many patients in border counties can access Northern Ireland hospitals more easily than hospitals in the Republic.

The use of these schemes has grown significantly in recent years, driven by the lengthening of HSE waiting lists and the increasing awareness among patients of their rights under EU and bilateral healthcare arrangements. The HSE has been required to publicise the schemes more actively following a series of cases in which patients were not informed of their rights, and the increased awareness has contributed to the growth in uptake.

Key Developments

The data on cross-border healthcare use paints a picture of a health system under severe strain. The figure of 232 patients from County Mayo using the schemes between 2024 and 2025 is striking — Mayo is a relatively rural county with a population of approximately 130,000, and the fact that more than 200 of its residents felt the need to seek treatment abroad in a single year reflects the depth of the waiting list problem in the west of Ireland.

The scale of the Northern Ireland dimension is particularly significant. Private facilities in Northern Ireland — including Kingsbridge Hospital in Belfast, which has developed a specific service model for patients from the Republic — have treated thousands of patients from south of the border. Kingsbridge has invested in the infrastructure needed to manage the cross-border patient flow, including dedicated liaison staff who help patients navigate the reimbursement process and coordinate their care between the Northern Ireland facility and their GP or consultant in the Republic.

The reimbursement model is the most significant limitation of the cross-border schemes. Patients must pay for their treatment upfront — which can involve costs of several thousand euro for surgical procedures — and then claim reimbursement from the HSE. The reimbursement process can take weeks or months, and the upfront cost is a significant barrier for patients who do not have the financial resources to fund their treatment in advance. This creates a situation in which the cross-border schemes are effectively available only to patients who can afford to pay upfront — a two-tier system that contradicts the principle of universal healthcare access.

Cases have emerged in which patients were forced to seek care abroad due to administrative errors on HSE waiting lists — situations in which patients were removed from waiting lists without their knowledge, or in which their referrals were lost in the system. These cases have generated significant media coverage and political pressure on the HSE to improve its waiting list management systems.

Why It Matters

The growth of cross-border healthcare use is a symptom of a health system that is failing to meet its obligations to its citizens. In a country that has committed to a universal health service through the Sláintecare programme, the reality that thousands of patients are having to seek treatment abroad — and to pay upfront for the privilege — is a fundamental contradiction.

The equity dimension of the cross-border schemes is particularly troubling. The schemes are, in theory, available to all patients on HSE waiting lists. In practice, they are accessible primarily to patients who have the financial resources to pay upfront and the knowledge and confidence to navigate the reimbursement process. Patients from lower-income backgrounds, patients with limited English, and patients in rural areas with poor access to information are all less likely to use the schemes, even if they are equally in need of treatment.

The cross-border dimension also has implications for the relationship between the health services in the Republic and Northern Ireland. The flow of patients from the Republic to Northern Ireland for treatment is a form of cross-border cooperation that is happening organically, driven by patient need rather than by policy design. It raises questions about whether a more structured approach to cross-border health cooperation — building on the existing schemes and the work of the North-South Ministerial Council — could deliver better outcomes for patients on both sides of the border.

Local Impact

In border counties — Donegal, Cavan, Monaghan, Louth, and Leitrim — the cross-border healthcare schemes are particularly significant. Patients in these counties often have easier access to hospitals in Northern Ireland than to hospitals in the Republic, and the schemes provide a formal mechanism for accessing that care with HSE reimbursement. The Letterkenny University Hospital in Donegal, which serves a large catchment area with limited specialist services, has been particularly affected by the waiting list crisis, and many Donegal patients have used the cross-border schemes to access treatment in Derry or Belfast.

In Mayo, the 232 patients who used the schemes between 2024 and 2025 represent a significant proportion of the county's population. Mayo University Hospital in Castlebar has been under sustained pressure, with waiting lists for several specialties extending to years rather than months. The cross-border schemes have provided a lifeline for some patients, but the upfront cost has been a barrier for others, and community health advocates in the county have called for the HSE to develop a more proactive approach to informing patients of their rights.

In Dublin, the cross-border schemes are less commonly used — the concentration of specialist services in the capital means that waiting lists, while long, are generally shorter than in more rural areas. However, the schemes are used by some Dublin patients for specific procedures where the wait in the Republic is particularly long, and the HSE's reimbursement office in Dublin processes a significant volume of claims from patients across the country.

What's Next

The HSE is expected to publish a review of the cross-border healthcare schemes in the coming months, examining the uptake, the equity implications, and the administrative processes involved. The review is expected to make recommendations for improving the accessibility of the schemes, including measures to reduce the upfront cost barrier and to improve the information available to patients about their rights.

The Sláintecare Implementation Advisory Council has also indicated it will examine the cross-border schemes as part of its broader review of progress towards universal healthcare. The council's recommendations, expected in the autumn, are likely to include proposals for a more structured approach to cross-border health cooperation that goes beyond the existing reimbursement schemes.

In the longer term, the growth of cross-border healthcare use is likely to prompt a broader conversation about the relationship between the health services in the Republic and Northern Ireland. The all-island health cooperation that has developed organically through the cross-border schemes could, with the right policy framework, be developed into a more systematic and equitable approach to delivering healthcare across the island — an approach that would benefit patients on both sides of the border and that would reflect the increasingly integrated nature of life on the island of Ireland.