Using all of our health service facilities has helped against Covid-19. Any change to that should be handled carefully

Dr Ciarán Ó Riain says the current system is necessary if we are to maintain healthcare for all and protect patients in any future infection waves.

AS THE FIRST wave of the Covid-19 pandemic appears to ebb in Ireland, some of the focus has now shifted to dealing with the inevitable backlog of non-Covid healthcare needs.

In particular, decisions are required about the role that independent private hospital facilities should play in the coming months. Planning for a worst-case scenario during this pandemic led to these being leased to the State at a reported cost of hundreds of millions of Euro.

Due to the national effort to ‘flatten the curve’, care of patients with Covid-19 has taken place predominantly in public hospitals without requiring significant use of private hospital beds.

With leased private facilities operating at low occupancy levels during this time, some recent commentary has come close to anointing this as the latest national scandal. Some perspective around the global context of these arrangements, their initial purpose and future potential is required.

A necessary move

The requirement for creating capacity was clear from the devastating images from Italy and governments around the world took steps to free up beds for Covid-19 patients and to ensure there were facilities where high priority procedures could be performed with relative safety throughout the pandemic.

Importantly, they also restricted other categories of non-urgent consultations and elective procedures, in line with public health and medical society guidelines. This was in order to preserve resources and prevent virus transmission to patient or practitioner. 

These restrictions devastated the business model of private hospitals worldwide. While the degree of public intervention in the private sector differs between countries, reduced occupancy of beds has been a common feature globally.  

Newspaper headlines in England have referred to private hospitals being ‘sinfully empty’ after a deal there that took over 8000 beds and reportedly reimbursed the private sector at cost. 

The Australian government restricted surgical theatre use at private hospitals to 25% of capacity as part of a two billion dollar ‘viability guarantee’. While private hospitals in New Zealand are also reported to be largely empty, there have been no such financial guarantees, as Prime Minister Ardern appears mindful of favouring particular businesses that have lost revenue. Even in the USA, there have been some government subsidies as cancellations lead to low bed occupancy and huge financial losses.

Healthcare hasn’t stopped

The value and beneficiaries of such public-private arrangements always warrant scrutiny. However, claims that the excess capacity in a private system could have been utilised more to continue routine private practice care should take into account this global public health context. 

As low bed occupancy figures have been seen around the world, such crude figures tell us little about how well our private facilities have been utilised as a part of this arrangement. 

Given that many consultations and procedures have been restricted by public health guidelines, a better metric might be to assess what proportion of typical ‘allowable’ non-restricted workload has been facilitated.

As we decide on a way forward, it is worth reflecting on what the Irish arrangement has been able to achieve. Surgeons from my own public hospital cancer centre have travelled to private institutes to perform ‘time-sensitive’ surgery on over a hundred patients.

Unlike the publicly resourced National Treatment Purchase Fund, this arrangement maintains continuity of care and utilises the skills of public hospital practitioners and subspecialist multidisciplinary teams.

As a surgical pathologist, I have been as busy dealing with complex gynaecological cancer surgery work over the last two months as in any previous year. In this way, cancer patients of both public and private centres have been able to access treatment in an equally safe environment. 

Perhaps more of such cooperative and innovative links could have been arranged across the country over the last two months. However, as requests to return capacity to the private sector or to ‘go back to the way it was’ grow louder, it is worth noting that the fundamental reasons for leasing the private hospitals still pertain.

Why keep it this way?

Firstly, the need for surge capacity. The virus hasn’t gone away. The crisis is not over. Rising numbers of cases in countries that have lifted restrictions demonstrate the potential for further surges. 

Admissions to hospital for acute medical care are returning to normal levels, discharges are delayed as facilities such as residential care homes and nursing homes protect their residents and staff. Further reduction in capacity could yet see minor surges overwhelm a system already short of beds and staff.

The other priority of facilitating safe healthcare will require a balancing act between the vital need to return to routine work and keeping our patients, staff and facilities safe. Mooted measures such as two-week quarantine and testing prior to procedures remind us that how healthcare works will change significantly. There are new finite resources to consider, not only tangible stock items such as personal protective equipment and anaesthetic drugs but also time and space.

In order to maintain a safe environment, most aspects of healthcare will take longer and need more room. 

Addressing these priorities and minimising the overall harm and deaths from Covid and non-Covid causes requires a response for the here-and-now and is particular to the circumstances of the pandemic.

Working out exactly how Covid-19 may change our approach to health in Ireland can perhaps wait until at least after the flu season, particularly as none of us can reliably predict the social and economic position of the country in 2021. 

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With all the talk of our system not being overwhelmed, it is easy to overlook how much care has been required for thousands of people hospitalised with Covid-19. The significant burden of this direct care for Covid-19 patients has fallen primarily on our public facilities.

Ongoing care will require significant numbers of general beds, isolation rooms and critical care beds in public hospitals. There will be staff absences through illness and the need for isolation. The system-wide response has likely provided a publicly funded financial lifeline to many vulnerable private hospitals and has relatively protected their facilities from Covid-19. 

A return now to the status quo would mean that those relying on the public hospitals will find their care squeezed even further. It is worth remembering that all of us rely on the public hospitals.

As we move past the first wave of this pandemic into an uncertain and vulnerable few months, flexible arrangements that provide surge capacity and allow safe care should be sought. Any of us who have ever sought resources to improve our own little corner of the health service understand the need for value for public money.

Whatever the exact arrangements for the coming months, the guiding principle should be to maximise capacity and protect scarce resources across our system in order to treat as many people as possible as safely as possible and on the basis of need. Given all that has been achieved in the last few months, it should not be beyond our capabilities to find a fair way to do that.

Ciarán Ó Riain is a consultant surgical pathololgist.