Published on 17 April 2023

An investigation by the Ombudsman, Ger Deering, has found an unreasonable and inflexible  approach by the HSE in administering schemes that fund treatment abroad for healthcare which the State is either unable to provide, or unable to provide in a timely manner in Ireland.

In his report, ‘In Sickness and in Debt’, the Ombudsman says that some patients faced a fight to be reimbursed for the legitimate costs they had incurred for necessary treatment they received abroad - with many borrowing money and some falling into debt as a result. In other cases, approval to have treatment abroad was unreasonably refused or delayed.

The Ombudsman has set out 21 recommendations to improve the administration of the schemes for the benefit of patients who need these critical treatments.  Following discussions between the Ombudsman and new HSE Chief Executive Bernard Gloster, the HSE has agreed to implement the 21 recommendations in the Ombudsman’s report.

Ombudsman Ger Deering said:

“I very much welcome the decision of the HSE to implement the recommendations. Their implementation will have a significant positive impact on the lives of those who need to access treatment abroad, and will help ensure that decisions under the schemes are focused on the patient’s needs.”

The Ombudsman’s investigation included an examination of the EU Cross Border Directive scheme. Under the scheme, the patient pays for necessary treatment in another EU or EEA country upfront and then applies to the HSE for reimbursement of the cost of the treatment.

The investigation identified instances where the HSE refused to reimburse patients for treatment they had paid for and received abroad because:

  • A patient’s GP had not ‘signed’ a letter of referral he emailed to a hospital in Northern Ireland. This was despite the fact that it was clear that the letter was sent from the GP’s email address, and the GP had assured the HSE in writing that the referral was genuine. (See page 47)
  • A letter of referral from the Irish GP was addressed to the relevant section of a Northern Ireland hospital (the “ENT” Department) and not a named individual in the hospital.  The HSE refused to accept a subsequent amended referral letter from the GP. (See page 49)
  • While treatment of a patient took place in Belgium, an initial consultation took place while the Belgian consultant was in Ireland. (The waiting list for treatment in Ireland was four years.) (See page 37)
  • Prior to treatment in Poland, an outpatient consultation with a Polish consultant took place by phone, and not in person. The patient was in urgent need of treatment for chronic back pain. (See page 38)
  • A number of elderly patients who sought refunds for treatment were in receipt of UK pensions.  Due to the lack of information provided by the HSE these patients were unaware that the fact they were in receipt of a pension from another EU country would negatively affect their application.  The patients had borrowed significant amounts of money to have the treatment but received no reimbursement. (See pages 23 & 28)

The Ombudsman’s report also contains recommendations in relation to two other schemes: the Treatment Abroad Scheme and the Northern Ireland Planned Healthcare Scheme - a scheme brought in to provide for treatment in Northern Ireland following Brexit. A small number of recommendations are relevant to the Department of Health. It has accepted these recommendations. 

The Ombudsman’s report, ‘In Sickness and in Debt’ is available at

In Sickness and in Debt