Examining universal access to acute hospital care in Ireland during the first three months of COVID-19: Lessons from the policy process

Introduction

The COVID-19 pandemic presented an unprecedented global health crisis, laying bare deficiencies in social protection and structural inequalities¹. European states and their health systems found themselves confronted with heightened demands for swift policy action to mitigate the spread of infection and safeguard public health, which required a comprehensive reconfiguration of healthcare systems². The pandemic had a significant impact on local strategies, as it considered various attributes of healthcare systems, including their structural facets, the presence and influence of the private hospital sector, and the availability and occupancy rates of acute hospital beds^2–6. In response, adopted plans included ensuring sufficient physical infrastructure, securing extra essential equipment, and expanding and reorganising the healthcare workforce to effectively manage the surge in demand from COVID-19^2,5,7,8.

Although countries' responses to the pandemic showed varying levels of sustained effectiveness, research suggests that resilient health systems capable of effectively harnessing health surveillance with the fundamental pillars of Universal Healthcare (UHC) were often better prepared to safeguard their populations against the pandemic^9–13. As a set of health policy goals, UHC depends on ensuring access to comprehensive, appropriate, timely, and quality health services without imposing a financial burden¹⁴. The pandemic has underscored a renewed significance on universal access to healthcare, proving that when the healthcare needs of a portion of the population are unattended, the whole population is at risk¹². In response, some governments devised and implemented various UHC policy measures during COVID-19, emphasising enhanced health service accessibility and responsiveness for their populations^15–18.

Several European countries, including Ireland, England, Italy and Greece, utilised and integrated private hospitals into the public system response to ensure access to all hospital care for COVID-19 patients and critical non-COVID elective procedures^3,19. It is essential to distinguish that the engagements during the COVID-19 pandemic differed significantly from traditional public-private partnerships, usually associated with high-cost and long-term projects. Instead, private sector involvement in the pandemic response was characterised by urgent needs, limited supplies, unconventional methods, and notably shortened timelines compared to non-emergency situations¹⁹. In the context of UHC, the WHO defines private sector engagement as the meaningful inclusion of private providers for service delivery in mixed health systems²⁰. This requires a comprehensive approach to the governance of health systems, spanning both private and public sectors. The focus is on defining appropriate areas for private sector engagement and implementing governance strategies that align with the health system's goals, ensuring access to high-quality care and financial protection for patients, regardless of where they seek treatment^19–21.

Effective private-sector engagement mandates aligning private-sector initiatives with public-sector health goals, demanding a commitment to actively support the government's agenda^19,20. Previous research has investigated the involvement of the private sector in service delivery during the COVID-19 pandemic¹⁹, as well as the unique challenges associated with implementing universal healthcare in systems marked by a prominent two-tier public/private system^22–25. In addition, the literature underscores the significance of insights derived from private sector engagement during the COVID-19 emergency period, emphasising the importance of these learnings. This is particularly crucial considering the potential evolution of emergency policies as enduring features of health systems^26,27.

Against this backdrop, it's crucial to understand how universalist COVID-19 policies aimed at increasing public healthcare provision intersect and play out in healthcare systems with a strong private sector presence. This intersection gains heightened relevance within the Irish context, where the interplay between universalist COVID-19 policies and a substantial private sector holds particular significance. The emergence of UHC principles played a central role in responding to the COVID-19 crisis^17,18,28,29. Although additional capacity from the private sector was deemed necessary, the primary emphasis remained on upholding an equitable public sector-driven pandemic response³⁰. This positioning emphasises the study's contribution to unravelling the complexities of navigating universalist policies in the presence of a strong private sector within the Irish healthcare landscape.

Background

In March 2020, the Irish public health system - the Health Service Executive (HSE) and the Department of Health, concerned with the threat COVID-19 posed on existing capacity constraints in acute public hospitals, reached an agreement with the Private Hospital Association (PHA) entitled the Safety Net Agreement (SNA). This enabled the HSE to have sole control over private hospital capacity (19 private hospitals) for all Irish people from April to June 2020.

The Irish health system comprises a complex mixture of public and private financing and delivery. In 2019, pre-pandemic, the system was financed by general taxation (74%), voluntary health insurance (14%), and out-of-pocket payments (12%)³¹. There are 51 publicly funded hospitals in Ireland. The acute hospital sector comprises of three models: i) 32 public entities governed and run directly by the state; ii) 19 independently owned voluntary bodies funded by the state under Section 38 of the 2004 Health Act governed by non-profits, seven of which are owned by faith-based organisations with a further five having some degree of faith-based involvement in their governance arrangements; and iii) 19 private for-profit organisations^32–36. It was the 19 private for-profit hospitals which were the focus of the SNA.

Ireland's public healthcare system does not offer a comprehensive universal entitlement to healthcare, underscoring the intricate complexity of the system³². Eligibility and income mean testing exist for services specified under the 1970 Health Act. This divides Irish citizens into two categories: Category 1, individuals with full eligibility who qualify for the General Medical Card Scheme (31.8% of the population in 2019) based on means-testing receive free access to primary and acute care, and co-payments for prescription medicine³⁷. Category 2, individuals with limited eligibility pay out-of-pocket costs at full price or co-payment³². Some individuals are eligible for a GP visit card that allows patients under six years old and 70+ to access GP care without charge³⁸. Individuals whose income falls below a specific threshold (yet remains above the Category 1 income threshold) are also eligible for a GP visit card. In addition, in 2020, public hospital care included a €100 fee for emergency department visits without admission, except for individuals with a general practitioner's referral or those holding a medical card. There was a nightly charge of €80 for inpatient treatment, with an annual cap of up to €800^32,38.

UHC in Ireland is a contentious issue marked by power struggles and opposition from political and economic elites, religious institutions, and certain medical professionals^34,39,40. Despite gaining national independence in 1922, Irish public policy remained under the religious institutions powerful influence, which dominated key societal domains, including education and healthcare^34,40. During this time, the nation heavily depended on health services established and governed by religious orders, funded through a combination of charitable endowments, parliamentary grants, and a national lottery^34,40,41. However, a pivotal transformation has unfolded since the mid-1980s as the influence of the Catholic Church on Irish society has continuously waned. During this period, a significant paradigm shift emerged, with Irish political parties embracing market-driven solutions for the development of the healthcare system, reflecting the prevailing public policy trends seen in both the UK and the USA^34,41,42.

Over the past four decades, the promotion of market-based ideologies and neoliberal policies such as austerity-driven spending reductions and privatisation has been the driving force behind the substantial growth of the Irish private acute hospital sector, further complicating an already underdeveloped and under-resourced public healthcare system^34,43–48. As a consequence, the Irish healthcare system stands fragmented, marked by capacity constraints, a lack of universal entitlements, and long waiting times for essential care^{23,43,45,46,49,50}. The entitlement to the public health system becomes more theoretical than practical³⁹. Consequently, patients with adequate financial resources are incentivised to purchase private health insurance (46% of the population in 2019), providing faster access to care across the health system, including some public facilities⁵¹. As a result, significant disparities in health outcomes have emerged in Ireland, with vulnerable population groups experiencing disproportionate impacts in terms of poor access and quality^48,52–54.

In 2011, a political commitment was made for the first time to introduce UHC through the introduction of Universal Health Insurance (UHI) as a mechanism to end the two-tier hospital system in Ireland. Subsequently, a white paper detailing these intentions was published by the government in 2014 but was abandoned in 2015 on cost grounds^55,56. Nevertheless, UHC remained on the political agenda^57,58. Since 2017, there has been cross-party political support for 'Sláintecare' – Ireland’s 10-year national health policy, which is underpinned by a commitment to UHC and aims to establish a single-tier health system that provides timely access to quality care solely based on health need^59,60. However, implementation is slow⁶¹, supporting the view that there is an absence of clarity and agreement on definitions of UHC in Ireland, including universal entitlement to care and the mechanisms to achieve this^50,62.

Previous research has emphasised the significance of the SNA in Irish health policy, particularly its role in establishing a unified single-tier public acute hospital system – an unprecedented development for Ireland, albeit for a 3-month period^18,28,63. However, a knowledge gap remains regarding the specific mechanisms used to achieve this, along with the experiences and insights of stakeholders in the negotiation and delivery of the SNA. Addressing this gap presents a critical opportunity to better understand the policy process and to harness vital policy insights into public-private relationships in the healthcare sector that can guide future health reform efforts towards achieving UHC in Ireland.

Research aim

This research aims to comprehensively examine the SNA established between the HSE and Irish private hospitals in March 2020 as a case study within the Irish health system, where a UHC policy (within the acute hospital sector) was implemented in response to the COVID-19 pandemic. The primary objective of this research is to analyse all parts of the policy process, including the substantive content of the SNA, its contextual background, the roles played by various actors involved, and the mechanisms employed to enact this policy response. Through this investigation, valuable insights are derived from this specific policy change, offering a deeper understanding of UHC implementation in two-tier public/private health systems.

Methods

This study forms one of the workstreams within the Health Research Board (HRB)-funded Foundations’ research project that aims to harness key learnings from Ireland’s health system response to COVID-19 with a view to informing the implementation of Ireland’s ten-year health reform plan, Sláintecare^{17,29,38,64–66}.

The research employs a retrospective qualitative case study approach to explore the policy process regarding the agreement with Irish private hospitals to access capacity during the Covid-19 pandemic from March–May 2020. The research design incorporates two qualitative methods of: documentary analysis and semi-structured interviews.

The intricate nature of health policy and system responses during a crisis necessitates a qualitative approach, as qualitative research facilitates a comprehensive exploration of decision-making processes, stakeholder interactions, and contextual nuances crucial for capturing the multifaceted dynamics that shape policy outcomes^67–69. This approach is particularly relevant in Health Policy and Systems Research (HPSR), which aims to provide explanatory insights that inform health system improvements and outcomes⁷⁰.

Within qualitative research, case study methodology plays a central role and enables a detailed examination of specific health policy instances or system features^71,72. These in-depth investigations involve analysing formal documents, guidelines, and the actions of key stakeholders to describe and explain real-life phenomena of interest⁷³.

Two fundamental qualitative methods, documentary analysis and semi-structured interviews, are integrated to enhance the research's robustness. While documentary analysis offers a structured understanding of textual content, it may lack the full operational context⁶⁸. Semi-structured interviews complement this by providing full contextual depth and a broader perspective, thus bridging the gap between documented narratives and actual practice⁷⁴.

Findings

The findings below are presented as:

Figure 1. Timeline of Key Events^30,77–89.

Narrative timeline

In the initial quarter of 2020, as the COVID-19 pandemic unfolded in Europe, the Irish health system faced an unprecedented challenge in rapidly expanding its capacity to accommodate the increasing number of patients¹⁸. At the outset, Ireland grappled with a constrained supply of acute hospital beds and consistently high occupancy rates, with 250 critical care beds and 11,000 inpatient beds, which operated near 100% occupancy^40,41. Anticipating a surge in illness presenting at hospitals, the exhaustion of Ireland's limited ICU capacity coupled with a heightened awareness of Europe's evolving public health situation, health authorities and the state promptly launched a public health response.

The first and most crucial element of the state and health system approach to confronting the COVID-19 pandemic was on 28 February, the inclusion of COVID-19 in the list of notifiable infectious diseases stipulated in the Infectious Disease Regulation 1981 of the 1947 Health Act⁸⁰. This legislative provision was explicitly crafted to contain the spread of infectious diseases and exempt patients from statutory public hospital charges.

On 16 March, the government published Ireland’s National Action Plan in Response to COVID-19³⁰, delineating strategies for ensuring sufficient access to hospital care for the public. The plan outlined measures that the HSE and the Department of Health would undertake to bolster bed and hospital capacity, including forging partnerships with the private hospital sector. From the outset, there was substantial support for collaborating with the private sector. What became evident during the qualitative interviews was that this support stemmed from the determination of officials and politicians to increase capacity to ensure universal and equitable access to COVID-19 care, aligning with the mantra of the Infectious Disease Regulation and existing policy objectives of 'Sláintecare'⁵⁹. This approach was encapsulated in ‘we’re all in this together’ which was often cited during interviews and resonated throughout the media during the initial stages of the pandemic^81,82.

In response to the government's mandate as outlined in Ireland’s National Action Plan, the HSE and the Department of Health engaged in an intensive three-week negotiation process with the Private Hospital Association (PHA), the representative body for the private hospital sector in Ireland. The central objective of these negotiations was to secure the utilisation of private hospital facilities for Ireland's public health system in anticipation of the surge of COVID-19 cases. Once negotiations were finalised, public health officials presented a 'Framework for Pandemic Response' to the government for approval, outlining the workings of the collaborative engagement between the HSE and private hospitals to secure additional hospital capacity (see Figure 2)⁸³. On March 30, 2020, the government granted its approval⁸⁴. Under this framework, all patients in Ireland would be considered ‘public’ for the duration of the agreement, granting them access to treatment in both public and private hospitals^83–85. Furthermore, the public health system would gain access to an additional 2,500 private hospital beds, including over 100 critical care beds and 200 ventilators⁷⁹.

Figure 2. Details of ‘Framework of Pandemic Response’⁸³.

Most consultants in Irish private hospitals operate as independent contractors. There are some specific instances where they are employed directly by the private entity. In the Framework for Pandemic Response, it was decided that the state would offer existing private-only consultants (who would have had no state contract) a 'Type A' contracts for the duration of the SNA (see Figure 3), allowing them to participate in public healthcare work exclusively^84–88 (see Figure 4).

Figure 3. Summary of consultant contracts available in the Irish public health system in 2020⁹⁵.

Figure 4. Details of the contract offered to Private Hospital Consultants under the Safety Net Deal^{80–83,94,95}.

Following the government's approval, on 1 April, the HSE offered 'Type A' contracts to consultants who only work in private hospitals⁸⁸. Heads of Terms (HoT) were drafted per the previously established 'Framework for Pandemic Response' document⁸⁴. Nineteen private hospitals signed the HoT on 2 April 2020⁸⁴. Consequently, the public health system gained access to the entire capacity of the private hospital system for an initial three-month period, with a provision to extend the arrangement as required. No private work was permitted in any private hospital during this time.

Simultaneously, the government made a critical decision following a recommendation from the National Public Health Emergency Team (NPHET) on 27 March to postpone all non-essential healthcare services across the public system⁸⁹. The decision was made to safeguard capacity in public hospitals and mitigate the risk of infection transmission within hospital premises by reducing patient attendance^38,90–92. During this period, the available capacity in the private hospitals was used to support the HSE in delivering urgent and time-dependent treatments and procedures, particularly cancer treatment, cardiovascular surgeries, transplant surgery, chemotherapy, radiological tests, and procedures⁸⁴. Moreover, the private hospital capacity remained readily accessible as the need arose, aligning closely with the original primary objective of the arrangement⁸⁵. However, it is also noteworthy that the suspension of non-essential care, accompanied by the 'buy out' agreement, prevented substantial financial losses for the private sector. This mutually beneficial arrangement offered the private sector a stable income during a highly uncertain period when their business model was particularly vulnerable.

As the rising cost of the SNA began to emerge and the COVID-19 surge expected and planned for never materialised, the political consensus supporting the deal started to wane, leading to public, political and media commentary on the agreement’s efficacy^{63,79,92–97}. Towards the end of the agreement, in June 2020, it was suggested that the public system did not utilise the full available capacity provided for under the agreement and that, at €300 million for three months (versus €471 million for six months initially put to government) the deal was not providing value for money⁷⁹.

Stakeholders involved in the agreement’s negotiation and delivery shared government views that the private hospital arrangement was not used to maximum effect⁹⁸. Then Secretary-General of the Department of Health, Jim Breslin, responded to the criticisms of capacity under-utilisation stating, 'A fire alarm went off, and we sent four fire tenders to put out the fire, and people are now saying we should have sent only three. I am very happy that we sent four fire tenders because what if it needed more than three’⁷⁹.

After three months, on 30 June 2020, the government instructed the HSE to terminate the existing HoT and, together with the Department of Health and the Department of Public Expenditure and Reform, to negotiate a new contract with the private hospitals to provide additional public capacity⁹².

Discussion

This research examines the policy process surrounding the SNA established between the HSE and Irish private hospitals in March 2020, serving as a case study within the Irish health system. Employing qualitative methods of documentary analysis and semi-structured interviews, the study comprehensively analysed the policy process, including the content of the SNA, its contextual foundations, and stakeholders' various experiences and roles. This investigation provides valuable insights into the influence of the medical profession and public administrative capacity to engage the private sector. It allows us to garner lessons on the governance of public-private relationships in the healthcare sector with the aim of achieving universal access to COVID care within an existing two-tier acute hospital system. Additionally, it enables us to draw possibilities worth considering for future health reform.

In response to the surge in COVID-19 cases in Europe, one of the initial measures taken by Government to combat the spread in Ireland was its inclusion on the list of notifiable infectious diseases specified under the 1947 Health Act⁸⁰. This legislation was initially championed by then Minister for Health, Dr Noel Browne, as part of his broader efforts to universalise health services for the Irish population and, at the time, was designed to curb the spread of TB during the late 1940s and early 1950s. It included provisions to exempt all patients suffering from a notifiable disease from statutory public hospital charges^34,40. This legislation set the foundation for universal, equitable access to COVID-19 care in Ireland in 2020, including all public and private hospital provision.

The Irish government and key public health officials quickly recognised a significant challenge in implementing crucial health policy measures due to the insufficient and restricted capacity of public healthcare services. Rapidly scaling up and deploying essential new services are considerably more complex in a system lacking UHC principles^{10–13,104,105}. This challenge became particularly evident when public hospitals faced the risk of being overwhelmed, ensuring that access to COVID-19 treatment was not contingent on financial means and eliminating scenarios where individuals could "skip the queue" – a reality in Ireland's two-tier hospital system^{45,49,50,53,62}. Ireland’s experience demonstrates the significance of agile responses and rapid implementation of health policy measures including universal access to hospital care through the SNA^17,18,29,63. This move starkly contrasts the historical rigidity and siloed nature of public and health system bureaucracies and entrenched neoliberal policies in Ireland^{46,54,106,107}.

As the SNA was agreed and rolled out, private hospital consultants effectively wielded political influence and leveraged their private patients to advocate for amendments to their terms and conditions. Public health officials perceived this strategy as a successful attempt by consultants to safeguard their independence and income, thereby shaping policies in their best interests. The negotiation processes surrounding consultant contracts highlight the enduring influence and gatekeeping role of the Irish medical profession, which employs its terms and conditions to impede transformative changes in the Irish healthcare domain³⁹. This obstruction is particularly evident in efforts to reform policies toward UHC and threaten private practice rights^{34,40,41,47,48}.

Insights from health systems and policy research highlight how poorly designed relationships with the private sector can weaken existing public structures, compromising the goals and desired outcomes^19,21,108. Health reform carries substantial ethical implications and necessitates political decisions that involve extensive negotiations with various interest groups. This process often alters the distribution of entitlements, responsibilities, and resources within the health system^67,109. These elements are evident in this case study. Such changes can influence a diverse range of stakeholders with varying interests, power dynamics, and levels of influence, thereby creating both political opportunities and tensions^67,110. Depending on the financial conditions, incentives, and intellectual influence related to their contributions, actors can impact the health policy process and reform^{67,104,109,111}.

This research identified critical disjunctures between public and private actors in negotiating and delivering the SNA. The absence of clearly defined policies governing private sector engagement and the ambiguous understanding of the public-private mix in the Irish context hinder the health systems' ability to effectively execute agreements in the public interest. Establishing clear guidelines for interaction between the public and private sectors in non-crisis times is crucial for building trust and fostering robust partnerships and would help ensure better relationships and responses during times of crisis^19,21. Currently, the private sector's commitment to aligning with public health goals is compromised by the lack of explicit medium and long-term policies and agendas^112–114, complicating the realisation of shared objectives, including universal healthcare.

The evolving policy landscape of private sector utilisation during the COVID-19 pandemic highlights a significant transformation where an agreement becomes a complex facet of the health system's response to capacity challenges^26,27, introducing dual policies on private sector engagement. The Irish public health system has been grappling with longstanding challenges for over two decades, exacerbated by difficulties post-pandemic and a May 2021 cyber-attack^115–117. While these challenges are not unique to Ireland^115,118, strategies to address backlogs, such as the National Treatment Purchase Fund (NTPF) and direct procurement by the HSE from private hospitals, reflect a fragmented policy approach. Recognising the effectiveness of one-off additional funding strategies, such as purchasing care from the private sector for short-term relief, is acknowledged that these approaches do not ensure sustained reductions in waiting times¹¹⁹. Echoing this pattern, the NTPF initially reduced waiting numbers, but these improvements were unsustainable, resulting in persistent waiting times a decade later⁴⁴. This study emphasises the critical need for reassessing dual and overlapping strategies in private procurement within Ireland's public health system, highlighting the potential drift towards privatisation¹²⁰, thereby threatening the core objective of addressing capacity issues in public hospitals.

Finally, the SNA introduced new insights, leading public officials to contemplate consolidating public and private capacities for universal access to elective hospital care potentially through a UHI model. While a UHI model had been explored in 2011, it was abandoned in 2016 due to cost concerns⁵⁵. The SNA provides precise cost estimates for running the private hospital system and a comprehensive assessment of the system's total capacity—a previously elusive figure. Policymakers drew inferences from this, and considered re-evaluating pathways to a UHI model for hospital care in Ireland, aligning with insights explored by Thomas et al. in 2008^33,121.

Conclusion

The emergence of the COVID-19 pandemic compelled the Irish government and policymakers to navigate unprecedented challenges, prioritising public health and equitable access to care amidst the impending crisis. However, this period of private hospital sector engagement also provided valuable insights into the public healthcare system, offering stakeholders critical knowledge and experience that could potentially guide achieving universal access to hospital care in Ireland post-COVID.

This research sheds light on the intricate policy process dynamics surrounding the negotiation and delivery of private hospital agreements in delivering universal hospital care during the COVID-19 pandemic in Ireland for a three-month period. It underscores the crucial role of broader socio-political contexts and the influence of various stakeholders - including government officials, policymakers, and the medical sector – and uncovers the complex and contested terrain within which struggles over UHC implementation during a crisis occur.

By exploring opportunities, challenges and dilemmas encountered when navigating the intersection of public and private healthcare in a dynamic socio-political context, this research offers important lessons for health system reform in Ireland and internationally. In particular, crucial insights are gleaned that potentially contribute to developing clear long-term goal alignment, robust governance practices, and trust-building mechanisms for successful public-private collaborations in two-tier health systems, informing future healthcare policy and implementation strategies.

Ethical and security consideration

In this research article, data were derived from two primary sources: documents and interviews. The interview transcripts are not being uploaded to a repository, even in anonymised form, due to the sensitive nature of the interviews and the explicit guarantee of complete confidentiality and anonymity provided to the interviewees in their informed consent forms. Respecting the ethical commitments made to the interviewees and in alignment with the approval obtained from the Research Ethics Committee of the Centre for Health Policy and Management and Centre for Global Health in Trinity College Dublin’s School of Medicine in Trinity College Dublin, we cannot provide the interview transcripts. Any violation of these agreements could undermine the trust established with the research team, potentially causing harm to the integrity of the study.

It is important also to note that, given the relatively small size of those involved in this case study and in the policy community in Ireland, both historically and presently, revealing anonymised transcripts, may lead to revealing interviewees' identities by individuals working in health policy in the country. Such recognition could compromise the confidentiality promised to the participants and jeopardize the relationships fostered during the research process.