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Healthcare costs amongst EU member states have grown from a historically low, or non-existent if you go back to Dickensian England, to now consuming substantial percentages of overall GDP. The West, bar America, has increasingly become committing to providing low-, or no-, cost healthcare to the population.
In the UK it’s argued that this came about due to WW2 leading to a need for the Government to ‘reward’ the population for its participation in the slaughter – apparently not everyone shared Ernst Jünger’s appreciate for the good time of the wars – and to take care of those wounded in it. One would expect that that dynamic, large numbers of wounded who had fought for their country and would expect their country to now fight for them, was replicated across most European countries after the closure of the war.
It’s an interesting change from what we see in the treatment of veterans after earlier wars and up to the start of WW1. Contemporaneous accounts, novels, poems, etc, frequently discuss the sight of the maimed veteran reduced to a beggar. But we digress.
Anyway data now shows healthcare consuming upwards of 10% of national GDP across Europe, with the trend likely to become even more destructive as populations age. In a rare reversal of their usual lack of focus the EU Parliament saw this coming nearly three decades ago. A 1998 Working Paper acknowledged that Member States were already struggling to maintain quality while keeping costs under control, warning that the volume of care required was “starting to exceed the resource base.” The culprits identified back then were the same ones we point to now: people living longer and expecting more from the system when they do get sick. Twenty-seven years later, the problem is worse.
Closer to home, the Irish Parliament’s Parliamentary Budget Office (PBO) has had a go at quantifying exactly how bad things are. Its latest Working Paper, Benchmarking Public Health Spending Efficiency in Europe: A Data Envelopment Analysis (DEA) Approach, puts numbers on what most people already feel in their bones.
Ireland’s score in that work puts it below countries that spend substantially less per capita. Portugal spends just over half of what Ireland spends per person, and achieves comparable life expectancy outcomes. Spain, coming in at roughly two-thirds of Ireland’s per-capita spend, laps us on several composite health indicators. The question is not whether Ireland spends enough. It self-evidently does. The question, from the public perspective, is “How much of the tax I am paying is making things better and how much is just dumped into a bottomless hole or set on fire?”
Part of the answer is probably staring us in the face in how health services actually buy things. In Ireland the HSE spends roughly €720 million a year on agency staff, a bill that exists for one reason: the permanent hiring system cannot fill posts fast enough to keep wards staffed. It also often can’t fill them quickly enough, whereas agency workers can be there, if you’re lucky, within days. Next day delivery is not out of the question.
That does mean that agency staff are considerably more expensive, typically by a factor of 1.5 to 2.5, than normal staff, depending on the grade and speciality.
Amusingly Ireland produces quite a large number of doctors each year, we’re simply unable to actually keep them here.
The HSE has acknowledged this repeatedly and committed to reducing agency dependency repeatedly. The spend has continued to grow.
What the PBO’s analysis captures in aggregate, these specific cost patterns illustrate at the operational level. You don’t arrive at an efficiency score of 0.55 through one bad decision.
ou get there through dozens of individually reasonable choices that, stacked on top of each other, end up routing money toward keeping the system running rather than making people better. Both the PBO and the broader European numbers point the same way: what countries spend and what their populations get for it are far less connected than anyone paying taxes into the system would hope. ‘Weak relationship’ is the polite framing. ‘Dysfunctional’ is the more honest one.
What the PBO set out to do was relatively straightforward in concept if not in execution: line up European countries side by side and measure how efficiently each one turns public health spending into things that actually matter, like whether people live longer and get sick less often. Ireland was benchmarked against its European OECD peers.
Basically Ireland is outcome-strong but markedly input-intensive. We get decent results. We get bent over when we pay for them.
And yet are EU citizens actually happy with their healthcare? You can probably guess the answer to this one, and not only because the voting public are never happy about anything other than politicians taking pay cuts; even there they may be unhappy that the cuts weren’t larger.
You would think that spending this kind of money would at least buy public satisfaction. It does not. The gap between what European governments pour into health and what their citizens feel they get back is, to put it mildly, substantial.
Anyone who has sat through a health committee session in any parliament will recognise the question that dominates proceedings, session after session, year after year: where is the money going?
In 2025 the OECD tried to answer that question directly by producing the ‘Does Healthcare Deliver? Results from the Patient-Reported Indicator Surveys (PaRIS)’ report. It was a fairly impressive undertaking which looked at ten indicators, across two categories, to attempt to capture what patients actually thought about the standard of care they had/were received/receiving.
Generally the OECD’s findings tracked pretty closely with what the PBO found in Ireland. Spending more money did track with better physical health, which is about as surprising as discovering that water is wet. But that was where the good news ended. Patient satisfaction, trust, whether anyone felt their GP and their hospital were actually talking to each other — on all of those, the connection between what a country spent and what its people reported back was thin to the point of meaningless. The OECD’s own reading was blunt: money alone cannot be relied upon to fix what’s broken
That two completely separate analyses, one Irish and one continent-wide, arrived at functionally the same answer is probably not a great sign.
A common refrain from people in Ireland is that the standard of care is very good, and that access is the problem. One could be forgiving for asking how we could consider the standard of care to be very good if people are dying waiting for that care, but I am a simple journalist and not the sort of high-level health ethicist who can explain to you how restricting access to healthcare, through restricting private healthcare capabilities, and thus leading to more people dying from preventable illness, is a morally upright thing because the distribution of deaths would be less dependent on income levels.
It does raise the interesting question of how we measure capability and ‘goodness’ in relation to health – is a system which returns worse results across the board, but can be quickly accessed by everyone, a better system than one in which access is limited but results are extremely good?
In America they decided that healthcare was a limited resource and that, beyond a certain level, money would be how they world determine how it was apportioned. This was widely condemned by European politicians as inhumane, but is a system which has instead organically grown to apportion medical care on the basis of a lottery system, or the raw luck of going to the right public hospital, actually the more humane one?
As an aside I would note that Ireland’s particular version of this problem is especially absurd because the two tiers often operate inside the same building. The same consultant who sees a public patient after a fourteen-month wait will see a private patient in the same hospital the following Tuesday. The care delivered is, in many cases, clinically identical. What differs is the queue. We’re basically rationing the product by income whilst allowing us to politely claim that we’re doing no such thing.
Both are systems designed on the sample principle – we don’t have enough of something and people desperately want it – in some cases it’s going to be the thing people want more than anything else. The Americans decided they needed a sorting method that was, let’s be honest, extremely American and probably tinged with their own particular views of the Protestant work ethic. Europe talked instead of duty, responsibility, and reward. But incentives matter, and the American system, whilst an issue if you’re poor, both draws in absolutely world class doctors and medical supplies, whilst also effectively subsidising global medical and healthcare concerns due to its willingness to spend obscene amongst of money on healthcare.
That last point is one worth noting given the current administration and its promises to cut healthcare costs in America. There has been an assumption in Europe that this will be undone due to their tariff policies, and costs will be passed along to the American patient. That is possible, but, given how much of the American healthcare market, and prices, are within reach of the administration it is probably more likely that healthcare firms will instead jack up prices in the rest of the world, whilst retaining competitive access to American healthcare markets, rather than risk becoming uncompetitive, or being restricted by the admin.
If that happens expect European healthcare costs to jump substantially, and at a time when European countries are not well placed to absorb exploding healthcare costs.
None of this falls evenly, either. If you’re poorer, you get sicker sooner. And when you do get the same illness as someone with more money, you’re less likely to recover as well from it. The entire premise of public healthcare is that getting sick shouldn’t bankrupt you or kill you based on your postcode. The data suggests the premise is not surviving contact with reality. And the purpose of a thing, fundamentally, is what it does, the outcome it produces.
If the patient is not the primary beneficiary of all this spending, who is?