Privatization in the Irish hospital sector since 1980

Privatization in the Irish hospital sector since 1980 Abstract Background Privatization has transformed health care systems over the last several decades. This article examines trends in bed supply in Ireland between 1980 and 2015 within the context of government policy on bed provision in a system of inequitable access to care. Ireland has not published bed data on private hospitals since the 1980s, even if they comprise about one-quarter of all hospitals. However, this article presents, for the first time, annual bed data since the 1980s collected from private hospitals and used to trace the evolution of bed supply over time. Methods Bed data were collected for private Irish hospitals for the years 1980–2015, mainly through direct requests to hospitals. Additional sources included the Irish Medical Directory, private health insurance data, hospital company records and newspaper archives. Results Subject to data caveats explained in the article, between 1980 and 2015, total inpatient beds decreased by 25.5% nationally. Inpatient bed numbers in private for-profit (PFP) hospitals rose from 0 to 1075 but decreased from 9601 to 5216 in private not-for-profit (PNFP) hospitals and from 7028 to 6092 in public hospitals (using the Irish hospital classification, beds in private hospitals increased from 1518 to 1910 but decreased from 15 111 to 10 473 in public hospitals). Also, by 2015, 24.1% of PFP hospital beds were day beds, compared to 17.7% for PNFP and 15.7% for public hospitals (using the Irish classification, by 2015, day beds accounted for 23.8% of beds in private hospitals and 16.1% in public hospitals). Conclusions Trends in bed supply in Ireland between 1980 and 2015 are documented empirically for all Irish acute hospitals and contextualized within government policy on bed provision. The Irish acute hospital system has experienced privatization reforms supported by the government over the last several decades. health systems, hospitals, Ireland, marketization, privatization Introduction Ireland has a mixed public–private system of hospital care. Health Service Executive (HSE) hospitals are publicly owned and funded, so-called voluntary hospitals are publicly funded but owned by religious or lay trusts, and so-called private hospitals are owned and funded privately. The development of a public system comparable to Britain’s NHS was obstructed historically by political and economic elites, the Catholic Church and the medical professions opposed to the ‘socialisation of medicine’ (p. 32 in Ref.1). Since the 1980s, government policy has supported the growth of for-profit care in the hospital system in several ways. First, publicly employed consultants (specialized doctors) have been allowed to engage in private practice in both public and private hospitals, so that they have traditionally privileged private patients, maintaining a two-tier health system. However, since 2008, new contracts have included incentives to treat more public patients.2,3 Second, private health insurance is subsidized by the state. Nearly half the population have private insurance and can claim tax exemptions on insurance costs. The cost of this to the state was €448 million in 2012.2 Moreover, the cost charged to private insurers for accommodation of patients in public hospitals remains below the full economic cost.2 Third, two periods of austerity, in the 1980s and following the 2008 financial crisis, have squeezed the public system, resulting in lengthening waiting lists. From 1980 to 1989, real public health spending was cut by 7.5%, including a 9.7% cut in the general hospital program between 1985 and 19894 (Ref.4 and Table A.2 in Ref.1). Between 2008 and 2014, current public health expenditure decreased by 10.0%, including a decrease of 27.8% in capital spending on acute hospitals (Tables 6.1 and 6.3 in Refs.5,6). Between those two periods of austerity, however, real public health spending increased significantly, quadrupling between 1990 and 2008, in the context of Ireland’s rapid economic expansion.4 The reduced involvement of the state in health care opened the door to the for-profit sector. Reflecting on his time as Minister for Health in the early 1990s, Brendan Howlin (Labour Party) explained how he came to understand that maintaining a public health system of inferior quality was implicit in government support for private health insurance. He said: ‘The government wanted a chunk of the population—30% or thereabouts—to pay for private health insurance but, in order for that to happen, they really required the public system to be inferior. Why else, if it was first rate, would people pay for a private system?’ (p. 99 in Ref.1). Moreover, Jimmy Sheehan, the founder of Blackrock Clinic—Ireland’s best-known private for-profit (PFP) hospital—explained how health cuts led to the rise of PFP hospitals in the 1980s: the country faced ‘very considerable waiting lists for artificial joint surgery, as well as other high-tech areas such as open heart surgery’ due to health care rationing. ‘As a practicing surgeon I was frustrated with the lack of facilities, and it was that frustration that led to the development of Blackrock’.7 Fourth, between 2002 and 2010, the government implemented a program of tax incentives for investors in PFP hospitals, which boosted construction. For every €100 million in hospital construction, the government offered €44 million in tax breaks to investors (pp. 361–2 in Ref.8). Moreover, the National Treatment Purchase Fund was established in 2005, which allowed the government to pay PFP hospitals to treat patients on public waiting lists. Such incentives resulted in a mushrooming of PFP hospitals. The growth of the private sector in the Irish hospital system fits within the privatization trends witnessed in health care systems globally since the 1980s.9 This article examines trends in bed supply over time in Ireland’s acute hospital sector, which accounts for ~90% of total hospital beds in the country. Unfortunately, the Irish government has not compiled and published statistics for PFP hospitals and for a significant number of private not-for-profit (PNFP) hospitals since the 1980s. Reference databases (OECD, Eurostat, WHO) thus indicate ‘no data available’ for a number of key indicators. On the other hand, official Irish hospital statistics do exist for all public and some PNFP hospitals.10 However, these existing data are difficult to compare with other countries’ statistics because the Irish hospital classification system does not follow international norms that categorize hospitals into public, PNFP and PFP based on ownership.11 Thus, this article additionally presents a reclassification of Irish hospitals according to international standards and presents hospital data using both schemes so that readers familiar with either can interpret the data more easily. The absence of Irish private hospital data and idiosyncratic classification system has misled secondary research. For example, a RAND Corporation report on privatization trends in the hospital sector in four countries (Ireland, France, Germany, United States) suggested that there is no trend toward privatization in Ireland, which is not accurate. It stated: ‘We have observed an increasing trend towards hospital privatization and consolidation in three of the countries reviewed, France, Germany and the United States’.12 However, given the gaps in the data they were relying on for their analysis, their conclusion is understandable—OECD and Irish government data contain no information on PFP hospitals. Other work suffers from similar shortcomings. Ireland’s HSE publishes an annual in-depth analysis of the hospital sector.13 Yet, it is based exclusively on publicly funded hospitals, excluding PFP and many PNFP hospitals. It is thus difficult to paint a comprehensive picture of the Irish hospital sector and examine trends and developments within it precisely. Methods Reclassification of Irish hospitals This article is concerned with Irish acute hospitals. These comprise nearly all general and specialized hospitals (HP.1.1 and HP.1.3, in OECD-Eurostat-WHO coding).14 Mental health hospitals (HP.1.2), which account for ~10% of total hospital beds in Ireland, are excluded. It would be difficult to compile data on mental health hospitals because before 2009, mental health facilities were not differentiated into hospitals (HP.1.2) and non-hospitals (HP.2.2). In the Irish system, hospitals are classified as ‘public’ or ‘private’ whether their main funding source is public or private. The OECD-Eurostat-WHO methodology classifies hospitals differently, into public, PNFP and PFP according to criteria of ownership, corporate governance and revenue distribution. Public hospitals are those ‘owned or controlled by a government unit’, PNFP hospitals are not permitted ‘to be a source of income, profit, or other financial gain’ for their owners or those who control them, and PFP hospitals ‘are capable of generating a profit or other financial gain for their owners’ (p. 31 in Ref.11). All hospitals were reclassified following OECD-Eurostat-WHO norms.14 All ‘public non-voluntary’ hospitals in the Irish scheme were reclassified as ‘public’. All ‘public voluntary’ hospitals were reclassified as PNFP because they are controlled by entities other than government units. Private hospitals in the Irish classification were reclassified either as PNFP if their revenues are not distributed to their owners, or as PFP if their revenues are distributed to their owners (essentially, religious-owned hospitals were classified as PNFP and investors-owned hospitals as PFP). When hospitals changed their status at any point in time, their categorization was adjusted accordingly. Bed data Inpatient and day bed data were compiled for all acute hospitals in the country between 1980 and 2015. Inpatient beds are beds in which patients spend at least one night while day beds do not involve an overnight stay. Data were obtained differently for publicly and privately funded hospitals. First, the Department of Health publishes bed data for all publicly funded hospitals (i.e. all public hospitals and a number of PNFP ones). These data were used with one modification: district hospital beds were excluded for all years (official statistics did include district hospitals in 1980–91). Another issue should be noted: in 1980–92, it is the bed capacity that was recorded by the Department of Heath, namely, the number of physical beds in hospitals; since 1993, the number of available beds has been recorded, namely, beds that are staffed and ready to be used (Table G1 in Ref.15). Second, there are no published data on hospitals funded privately (i.e. all PFP and some PNFP hospitals) and these had to be collected—except for 1980–84, when the Department of Health did collect these data (bed capacity), used for this article. For 1984–2015, data were gathered via direct inquiries to hospital managers, bed managers and directors of nursing in undocumented private hospitals, as well as to religious orders that own hospitals. Inquiries were made both by email and by telephone both to current and past officers in every hospital (see Supplemental Table S1 for detailed data and sources). These data were complemented by the Irish Medical Directory,16 which has listed some bed numbers annually for some hospitals since 1993. Additional sources used to complete and confirm the data included the following: requests to Vhi Healthcare (the largest health insurance company in Ireland), local and national newspaper archives for mentions of bed numbers and hospital openings and closures (including ads placed by hospitals mentioning bed numbers), and hospital constitutions and annual reports.17 There are limitations to these data collected from private hospitals. First, they refer to bed capacity (the number of available beds could not be obtained because it requires data unavailable or lost by private hospitals, such as the daily number of staffed beds). They are thus directly comparable to official data for publicly funded hospitals in 1980–92 (which also refer to bed capacity). However, for 1993–2015, the Department of Health reports available beds for public hospitals, not directly comparable with bed capacity in private hospitals. But fortunately, in public hospitals, the difference between bed capacity and availability is small: <8% in 2016 and smaller in earlier years—2% in 1993 and 4% in 2005, for example—for both inpatient and day beds. (These percentages are calculated as follows. For 2016, national total bed capacity for publicly funded hospitals was 11 426 inpatient beds and 2234 day beds18 while bed availability was 10 592 inpatient and 2140 day beds (Table 3.1A, p. 36 in Ref.19)—a difference of <8% between inpatient beds available and bed capacity. In 2005, the difference was ~4%: 12 094 inpatient and 1253 day beds available (Table 1) versus 12 574 inpatient and 1197 day beds capacity (p. 65 in Ref.20) In 1993, the difference was less than 2% for inpatient beds (11 809 available and 12 000 capacity) (Table G1, p. 77 in Ref.15)). On the other hand, in private hospitals, there is a larger gap between bed availability and capacity (though no precise data are available). In sum, public and private hospitals’ bed numbers are more comparable in terms of bed capacity than bed availability. Second, data quality depends on hospital officers’ answers: for example, imprecise recall and deaths of officers in charge of bed management in past decades may all affect quality. Nevertheless, officers all had a direct role in bed management (they were hospital CEOs, bed managers, nursing directors, financial officers) and bed capacity is relatively easy to remember because it tends to remain stable except when major works are conducted in the hospital (opening or closing wards). As much as possible, data provided by one officer were cross-checked with another source. Results Trends in bed supply in the Irish hospital sector are shown in Fig. 1 and Table 1. Between 1980 and 2015, the total number of inpatient beds decreased by 25.5%, from 16 629 to 12 383. (The total number of beds in 1980 (16 629) refers to bed capacity, but the number of beds for 2015 (12 383) refers to available beds in publicly funded hospitals and bed capacity in privately funded hospitals. The 25.5% drop is thus subject to this caveat.) During this period, the country’s population rose from 3.4 to 4.7 millions,21 resulting in a decline in beds per capita from 4.89 to 2.63 beds per 1000 inhabitants. Table 1 Number of hospitals and beds in Ireland (international and Irish classifications), 1980–2015. Year International classification Totald Irish classification Publica Private for-profitb Private not-for-profitc Publice Privatef IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals 1980 7028 0 43 0 0 0 9601 36 60 16 629 36 103 15 111 36 87 1518 0 16 1981 7085 0 43 0 0 0 9543 26 58 16 628 26 101 15 093 26 85 1535 0 16 1982 7108 0 42 0 0 0 9496 26 58 16 604 26 100 15 106 26 84 1498 0 16 1983 7105 0 42 0 0 0 9573 0 58 16 678 0 100 15 163 0 84 1515 0 16 1984 7103 0 42 0 0 0 9309 17 57 16 412 17 99 14 890 13 83 1522 4 16 1985 7214 12 40 8 8 1 9202 25 56 16 424 45 97 14 898 25 80 1526 20 17 1986 7214 12 39 155 14 3 8874 55 54 16 243 81 96 14 583 49 79 1660 32 17 1987 6365 39 36 180 14 3 8199 44 51 14 744 97 90 13 078 53 74 1666 44 16 1988 6170 78 36 180 14 3 7015 166 43 13 365 258 82 11 726 207 66 1639 51 16 1989 6138 153 36 180 14 3 7087 214 40 13 405 381 79 11 766 324 63 1639 57 16 1990 6314 138 36 180 30 3 7091 202 41 13 585 370 80 11 912 284 63 1673 86 17 1991 6311 170 36 180 30 3 7161 258 41 13 652 458 80 11 979 368 63 1673 90 17 1992 6560 172 36 180 30 3 7064 363 41 13 804 565 80 12 136 462 63 1668 103 17 1993 6358 195 37 180 30 3 6939 398 40 13 477 623 80 11 809 516 63 1668 107 17 1994 6392 208 36 180 30 3 6950 390 41 13 522 628 80 11 853 521 63 1669 107 17 1995 6488 212 36 180 30 3 6974 426 41 13 642 668 80 11 953 543 63 1689 125 17 1996 6537 245 36 180 30 3 6849 429 39 13 566 704 78 11 937 583 62 1629 121 16 1997 6828 282 37 249 30 4 6363 421 37 13 440 733 78 11 861 612 62 1579 121 16 1998 6817 287 37 249 30 4 6267 462 34 13 333 779 75 11 788 636 60 1545 143 15 1999 6865 312 37 184 30 3 6278 487 35 13 327 829 75 11 781 673 60 1546 156 15 2000 6920 357 37 335 36 4 6116 485 34 13 371 878 75 11 891 721 60 1480 157 15 2001 7154 386 38 367 79 5 6027 516 33 13 548 981 76 12 036 771 60 1512 210 16 2002 7289 403 38 377 85 5 5997 532 30 13 663 1020 73 12 264 812 60 1399 208 13 2003 7350 492 37 409 85 6 5945 559 29 13 704 1136 72 12 299 909 59 1405 227 13 2004 7169 595 35 556 116 8 5714 679 25 13 439 1390 68 11 887 1132 53 1552 258 15 2005 7232 699 35 556 123 8 5880 724 26 13 668 1546 69 12 094 1253 54 1574 293 15 2006 7196 788 35 921 245 12 5780 810 24 13 897 1843 71 12 110 1418 53 1787 425 18 2007 7300 872 34 958 266 13 5688 856 24 13 946 1994 71 12 121 1545 52 1825 449 19 2008 7082 934 34 1015 276 13 5620 995 24 13 717 2205 71 11 847 1737 52 1870 468 19 2009 6822 985 33 1015 303 13 5571 979 24 13 408 2267 70 11 538 1772 51 1870 495 19 2010 6560 1019 32 1210 315 14 5407 1053 23 13 177 2387 69 11 159 1834 50 2018 553 19 2011 6358 1069 32 1214 309 14 5333 1090 23 12 905 2468 69 10 849 1913 50 2056 555 19 2012 6131 1101 31 1214 313 14 5203 1171 23 12 548 2585 68 10 492 2026 49 2056 559 19 2013 5995 1143 31 1214 341 14 5258 1101 23 12 467 2585 68 10 411 1998 49 2056 587 19 2014 6111 1135 31 1064 331 13 5211 1096 24 12 386 2562 68 10 480 1983 50 1906 579 18 2015 6092 1137 31 1075 341 13 5216 1121 24 12 383 2599 68 10 473 2003 50 1910 596 18 Year International classification Totald Irish classification Publica Private for-profitb Private not-for-profitc Publice Privatef IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals 1980 7028 0 43 0 0 0 9601 36 60 16 629 36 103 15 111 36 87 1518 0 16 1981 7085 0 43 0 0 0 9543 26 58 16 628 26 101 15 093 26 85 1535 0 16 1982 7108 0 42 0 0 0 9496 26 58 16 604 26 100 15 106 26 84 1498 0 16 1983 7105 0 42 0 0 0 9573 0 58 16 678 0 100 15 163 0 84 1515 0 16 1984 7103 0 42 0 0 0 9309 17 57 16 412 17 99 14 890 13 83 1522 4 16 1985 7214 12 40 8 8 1 9202 25 56 16 424 45 97 14 898 25 80 1526 20 17 1986 7214 12 39 155 14 3 8874 55 54 16 243 81 96 14 583 49 79 1660 32 17 1987 6365 39 36 180 14 3 8199 44 51 14 744 97 90 13 078 53 74 1666 44 16 1988 6170 78 36 180 14 3 7015 166 43 13 365 258 82 11 726 207 66 1639 51 16 1989 6138 153 36 180 14 3 7087 214 40 13 405 381 79 11 766 324 63 1639 57 16 1990 6314 138 36 180 30 3 7091 202 41 13 585 370 80 11 912 284 63 1673 86 17 1991 6311 170 36 180 30 3 7161 258 41 13 652 458 80 11 979 368 63 1673 90 17 1992 6560 172 36 180 30 3 7064 363 41 13 804 565 80 12 136 462 63 1668 103 17 1993 6358 195 37 180 30 3 6939 398 40 13 477 623 80 11 809 516 63 1668 107 17 1994 6392 208 36 180 30 3 6950 390 41 13 522 628 80 11 853 521 63 1669 107 17 1995 6488 212 36 180 30 3 6974 426 41 13 642 668 80 11 953 543 63 1689 125 17 1996 6537 245 36 180 30 3 6849 429 39 13 566 704 78 11 937 583 62 1629 121 16 1997 6828 282 37 249 30 4 6363 421 37 13 440 733 78 11 861 612 62 1579 121 16 1998 6817 287 37 249 30 4 6267 462 34 13 333 779 75 11 788 636 60 1545 143 15 1999 6865 312 37 184 30 3 6278 487 35 13 327 829 75 11 781 673 60 1546 156 15 2000 6920 357 37 335 36 4 6116 485 34 13 371 878 75 11 891 721 60 1480 157 15 2001 7154 386 38 367 79 5 6027 516 33 13 548 981 76 12 036 771 60 1512 210 16 2002 7289 403 38 377 85 5 5997 532 30 13 663 1020 73 12 264 812 60 1399 208 13 2003 7350 492 37 409 85 6 5945 559 29 13 704 1136 72 12 299 909 59 1405 227 13 2004 7169 595 35 556 116 8 5714 679 25 13 439 1390 68 11 887 1132 53 1552 258 15 2005 7232 699 35 556 123 8 5880 724 26 13 668 1546 69 12 094 1253 54 1574 293 15 2006 7196 788 35 921 245 12 5780 810 24 13 897 1843 71 12 110 1418 53 1787 425 18 2007 7300 872 34 958 266 13 5688 856 24 13 946 1994 71 12 121 1545 52 1825 449 19 2008 7082 934 34 1015 276 13 5620 995 24 13 717 2205 71 11 847 1737 52 1870 468 19 2009 6822 985 33 1015 303 13 5571 979 24 13 408 2267 70 11 538 1772 51 1870 495 19 2010 6560 1019 32 1210 315 14 5407 1053 23 13 177 2387 69 11 159 1834 50 2018 553 19 2011 6358 1069 32 1214 309 14 5333 1090 23 12 905 2468 69 10 849 1913 50 2056 555 19 2012 6131 1101 31 1214 313 14 5203 1171 23 12 548 2585 68 10 492 2026 49 2056 559 19 2013 5995 1143 31 1214 341 14 5258 1101 23 12 467 2585 68 10 411 1998 49 2056 587 19 2014 6111 1135 31 1064 331 13 5211 1096 24 12 386 2562 68 10 480 1983 50 1906 579 18 2015 6092 1137 31 1075 341 13 5216 1121 24 12 383 2599 68 10 473 2003 50 1910 596 18 Notes: Data in both the international and Irish classifications sum to the total column. IP, inpatient beds; D, day beds. aIP and D bed numbers refer to bed capacity (1980–92) and bed availability (1993–2015). bIP and D bed numbers refer to bed capacity (1980–2015). cIP and D bed numbers refer to bed capacity (1980–92) and a combination of bed capacity and availability (1993–2015) (the combination results from the aggregation of public voluntary beds (measured in bed availability) in the Irish classification and private not-for-profit beds (measured in bed capacity) among private hospitals in the Irish classification). dIP and D bed numbers refer to bed capacity (1980–92) and a combination of bed capacity and availability (1993–2015). eIP and D bed numbers refer to bed capacity (1980–92) and bed availability (1993–2015). fIP and D bed numbers refer to bed capacity (1980–2015). Data sources 1. Privately funded hospitals (private for-profit, some private not-for-profit, private (Irish classification)): Table S1 2. Publicly funded hospitals (public, some private not-for-profit, public (Irish classification)): Department of Health’s annual statistics series.15,19 However, this article excludes district hospitals for all years (the Department of Health included district hospitals in its data for 1980–91). Also, because the Health in Ireland: Key Trends series20 does not provide a breakdown of bed numbers by hospital, the Department of Health supplied these data to the author for 2011–15. To distinguish public voluntary and non-voluntary hospitals, for 1980–2003 data, voluntary and HSE/Health Boards hospitals are distinguished in Department of Health statistics and this classification was followed; but for 2004–15, hospitals are not distinguished in such a way in the published data, therefore, the annual Activity in Acute Public Hospitals in Ireland series13 was used (its Appendix I lists and classifies hospitals into voluntary and non-voluntary). Also, this article excludes Monaghan General Hospital’s 23 D beds in 2010–15 because it had no IP beds left, whereas Department of Health Statistics still counted its 23 D beds for those years. Table 1 Number of hospitals and beds in Ireland (international and Irish classifications), 1980–2015. Year International classification Totald Irish classification Publica Private for-profitb Private not-for-profitc Publice Privatef IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals 1980 7028 0 43 0 0 0 9601 36 60 16 629 36 103 15 111 36 87 1518 0 16 1981 7085 0 43 0 0 0 9543 26 58 16 628 26 101 15 093 26 85 1535 0 16 1982 7108 0 42 0 0 0 9496 26 58 16 604 26 100 15 106 26 84 1498 0 16 1983 7105 0 42 0 0 0 9573 0 58 16 678 0 100 15 163 0 84 1515 0 16 1984 7103 0 42 0 0 0 9309 17 57 16 412 17 99 14 890 13 83 1522 4 16 1985 7214 12 40 8 8 1 9202 25 56 16 424 45 97 14 898 25 80 1526 20 17 1986 7214 12 39 155 14 3 8874 55 54 16 243 81 96 14 583 49 79 1660 32 17 1987 6365 39 36 180 14 3 8199 44 51 14 744 97 90 13 078 53 74 1666 44 16 1988 6170 78 36 180 14 3 7015 166 43 13 365 258 82 11 726 207 66 1639 51 16 1989 6138 153 36 180 14 3 7087 214 40 13 405 381 79 11 766 324 63 1639 57 16 1990 6314 138 36 180 30 3 7091 202 41 13 585 370 80 11 912 284 63 1673 86 17 1991 6311 170 36 180 30 3 7161 258 41 13 652 458 80 11 979 368 63 1673 90 17 1992 6560 172 36 180 30 3 7064 363 41 13 804 565 80 12 136 462 63 1668 103 17 1993 6358 195 37 180 30 3 6939 398 40 13 477 623 80 11 809 516 63 1668 107 17 1994 6392 208 36 180 30 3 6950 390 41 13 522 628 80 11 853 521 63 1669 107 17 1995 6488 212 36 180 30 3 6974 426 41 13 642 668 80 11 953 543 63 1689 125 17 1996 6537 245 36 180 30 3 6849 429 39 13 566 704 78 11 937 583 62 1629 121 16 1997 6828 282 37 249 30 4 6363 421 37 13 440 733 78 11 861 612 62 1579 121 16 1998 6817 287 37 249 30 4 6267 462 34 13 333 779 75 11 788 636 60 1545 143 15 1999 6865 312 37 184 30 3 6278 487 35 13 327 829 75 11 781 673 60 1546 156 15 2000 6920 357 37 335 36 4 6116 485 34 13 371 878 75 11 891 721 60 1480 157 15 2001 7154 386 38 367 79 5 6027 516 33 13 548 981 76 12 036 771 60 1512 210 16 2002 7289 403 38 377 85 5 5997 532 30 13 663 1020 73 12 264 812 60 1399 208 13 2003 7350 492 37 409 85 6 5945 559 29 13 704 1136 72 12 299 909 59 1405 227 13 2004 7169 595 35 556 116 8 5714 679 25 13 439 1390 68 11 887 1132 53 1552 258 15 2005 7232 699 35 556 123 8 5880 724 26 13 668 1546 69 12 094 1253 54 1574 293 15 2006 7196 788 35 921 245 12 5780 810 24 13 897 1843 71 12 110 1418 53 1787 425 18 2007 7300 872 34 958 266 13 5688 856 24 13 946 1994 71 12 121 1545 52 1825 449 19 2008 7082 934 34 1015 276 13 5620 995 24 13 717 2205 71 11 847 1737 52 1870 468 19 2009 6822 985 33 1015 303 13 5571 979 24 13 408 2267 70 11 538 1772 51 1870 495 19 2010 6560 1019 32 1210 315 14 5407 1053 23 13 177 2387 69 11 159 1834 50 2018 553 19 2011 6358 1069 32 1214 309 14 5333 1090 23 12 905 2468 69 10 849 1913 50 2056 555 19 2012 6131 1101 31 1214 313 14 5203 1171 23 12 548 2585 68 10 492 2026 49 2056 559 19 2013 5995 1143 31 1214 341 14 5258 1101 23 12 467 2585 68 10 411 1998 49 2056 587 19 2014 6111 1135 31 1064 331 13 5211 1096 24 12 386 2562 68 10 480 1983 50 1906 579 18 2015 6092 1137 31 1075 341 13 5216 1121 24 12 383 2599 68 10 473 2003 50 1910 596 18 Year International classification Totald Irish classification Publica Private for-profitb Private not-for-profitc Publice Privatef IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals 1980 7028 0 43 0 0 0 9601 36 60 16 629 36 103 15 111 36 87 1518 0 16 1981 7085 0 43 0 0 0 9543 26 58 16 628 26 101 15 093 26 85 1535 0 16 1982 7108 0 42 0 0 0 9496 26 58 16 604 26 100 15 106 26 84 1498 0 16 1983 7105 0 42 0 0 0 9573 0 58 16 678 0 100 15 163 0 84 1515 0 16 1984 7103 0 42 0 0 0 9309 17 57 16 412 17 99 14 890 13 83 1522 4 16 1985 7214 12 40 8 8 1 9202 25 56 16 424 45 97 14 898 25 80 1526 20 17 1986 7214 12 39 155 14 3 8874 55 54 16 243 81 96 14 583 49 79 1660 32 17 1987 6365 39 36 180 14 3 8199 44 51 14 744 97 90 13 078 53 74 1666 44 16 1988 6170 78 36 180 14 3 7015 166 43 13 365 258 82 11 726 207 66 1639 51 16 1989 6138 153 36 180 14 3 7087 214 40 13 405 381 79 11 766 324 63 1639 57 16 1990 6314 138 36 180 30 3 7091 202 41 13 585 370 80 11 912 284 63 1673 86 17 1991 6311 170 36 180 30 3 7161 258 41 13 652 458 80 11 979 368 63 1673 90 17 1992 6560 172 36 180 30 3 7064 363 41 13 804 565 80 12 136 462 63 1668 103 17 1993 6358 195 37 180 30 3 6939 398 40 13 477 623 80 11 809 516 63 1668 107 17 1994 6392 208 36 180 30 3 6950 390 41 13 522 628 80 11 853 521 63 1669 107 17 1995 6488 212 36 180 30 3 6974 426 41 13 642 668 80 11 953 543 63 1689 125 17 1996 6537 245 36 180 30 3 6849 429 39 13 566 704 78 11 937 583 62 1629 121 16 1997 6828 282 37 249 30 4 6363 421 37 13 440 733 78 11 861 612 62 1579 121 16 1998 6817 287 37 249 30 4 6267 462 34 13 333 779 75 11 788 636 60 1545 143 15 1999 6865 312 37 184 30 3 6278 487 35 13 327 829 75 11 781 673 60 1546 156 15 2000 6920 357 37 335 36 4 6116 485 34 13 371 878 75 11 891 721 60 1480 157 15 2001 7154 386 38 367 79 5 6027 516 33 13 548 981 76 12 036 771 60 1512 210 16 2002 7289 403 38 377 85 5 5997 532 30 13 663 1020 73 12 264 812 60 1399 208 13 2003 7350 492 37 409 85 6 5945 559 29 13 704 1136 72 12 299 909 59 1405 227 13 2004 7169 595 35 556 116 8 5714 679 25 13 439 1390 68 11 887 1132 53 1552 258 15 2005 7232 699 35 556 123 8 5880 724 26 13 668 1546 69 12 094 1253 54 1574 293 15 2006 7196 788 35 921 245 12 5780 810 24 13 897 1843 71 12 110 1418 53 1787 425 18 2007 7300 872 34 958 266 13 5688 856 24 13 946 1994 71 12 121 1545 52 1825 449 19 2008 7082 934 34 1015 276 13 5620 995 24 13 717 2205 71 11 847 1737 52 1870 468 19 2009 6822 985 33 1015 303 13 5571 979 24 13 408 2267 70 11 538 1772 51 1870 495 19 2010 6560 1019 32 1210 315 14 5407 1053 23 13 177 2387 69 11 159 1834 50 2018 553 19 2011 6358 1069 32 1214 309 14 5333 1090 23 12 905 2468 69 10 849 1913 50 2056 555 19 2012 6131 1101 31 1214 313 14 5203 1171 23 12 548 2585 68 10 492 2026 49 2056 559 19 2013 5995 1143 31 1214 341 14 5258 1101 23 12 467 2585 68 10 411 1998 49 2056 587 19 2014 6111 1135 31 1064 331 13 5211 1096 24 12 386 2562 68 10 480 1983 50 1906 579 18 2015 6092 1137 31 1075 341 13 5216 1121 24 12 383 2599 68 10 473 2003 50 1910 596 18 Notes: Data in both the international and Irish classifications sum to the total column. IP, inpatient beds; D, day beds. aIP and D bed numbers refer to bed capacity (1980–92) and bed availability (1993–2015). bIP and D bed numbers refer to bed capacity (1980–2015). cIP and D bed numbers refer to bed capacity (1980–92) and a combination of bed capacity and availability (1993–2015) (the combination results from the aggregation of public voluntary beds (measured in bed availability) in the Irish classification and private not-for-profit beds (measured in bed capacity) among private hospitals in the Irish classification). dIP and D bed numbers refer to bed capacity (1980–92) and a combination of bed capacity and availability (1993–2015). eIP and D bed numbers refer to bed capacity (1980–92) and bed availability (1993–2015). fIP and D bed numbers refer to bed capacity (1980–2015). Data sources 1. Privately funded hospitals (private for-profit, some private not-for-profit, private (Irish classification)): Table S1 2. Publicly funded hospitals (public, some private not-for-profit, public (Irish classification)): Department of Health’s annual statistics series.15,19 However, this article excludes district hospitals for all years (the Department of Health included district hospitals in its data for 1980–91). Also, because the Health in Ireland: Key Trends series20 does not provide a breakdown of bed numbers by hospital, the Department of Health supplied these data to the author for 2011–15. To distinguish public voluntary and non-voluntary hospitals, for 1980–2003 data, voluntary and HSE/Health Boards hospitals are distinguished in Department of Health statistics and this classification was followed; but for 2004–15, hospitals are not distinguished in such a way in the published data, therefore, the annual Activity in Acute Public Hospitals in Ireland series13 was used (its Appendix I lists and classifies hospitals into voluntary and non-voluntary). Also, this article excludes Monaghan General Hospital’s 23 D beds in 2010–15 because it had no IP beds left, whereas Department of Health Statistics still counted its 23 D beds for those years. Fig. 1 View largeDownload slide Trends in hospital beds, 1980–2015. (A) Change in inpatient bed numbers since 1980 by type of hospital (international hospital classification). (B) As for A, but using the Irish hospital classification. (C) Day care beds as percentage of hospital beds, by type of hospital (international hospital classification). (D) As for C, but using the Irish hospital classification. Note: See Table 1 notes for caveats about data comparability over time and across series. Fig. 1 View largeDownload slide Trends in hospital beds, 1980–2015. (A) Change in inpatient bed numbers since 1980 by type of hospital (international hospital classification). (B) As for A, but using the Irish hospital classification. (C) Day care beds as percentage of hospital beds, by type of hospital (international hospital classification). (D) As for C, but using the Irish hospital classification. Note: See Table 1 notes for caveats about data comparability over time and across series. Between 1980 and 2015, the number of PFP inpatient beds rose from 0 to 1075. The first three PFP hospitals opened in the mid-1980s, followed by a large expansion in the 2000s, reaching a total of 13 in 2015. Between 1980 and 2015, the number of public beds decreased from 7028 to 6092. Many beds were closed in the late 1980s and since 2008 due to austerity measures. But the most significant decrease took place in the PNFP sector, whose inpatient bed numbers were nearly halved between 1980 and 2015, from 9601 to 5216. Many of these hospitals were funded by the government and closed due to spending cuts. Moreover, many were owned and managed by religious orders, which either lacked the financial resources to operate modern facilities, or whose members became too old to maintain services. Over the time period surveyed, PFP hospitals took over eight unsustainable PNFP hospitals. Similarly, in terms of the Irish hospital classification, between 1980 and 2015, inpatient beds dropped from 15 111 to 10 473 in public hospitals but increased from 1518 to 1910 in private hospitals (Differences between the numbers presented here and those in other reports are sometimes due to other reports including non-acute hospitals (e.g., p. 227 in Ref.22)). It is interesting to examine how the shift in the bed mix between inpatient and day beds has varied by hospital type (Fig. 1C and D). All hospitals began to use day beds in the 1980s, gradually increasing their numbers throughout the 1990s, and particularly in the 2000s. The main reasons for this development are technological advances permitting more rapid treatment for a range of procedures and public funding cuts that have restricted inpatient beds growth.23 PFP hospitals embraced day beds to the greatest extent, followed by PNFP and public hospitals. The more commercial hospitals thus restructured their bed mix more in favor of day beds: by 2015, 24.1% of PFP hospital beds were day beds, compared to 17.7% for PNFP and 15.7% for public hospitals. This is explained by the fact that public hospitals treat long-term illnesses to a greater extent than PFP ones, which focus on profitable, quicker procedures. Interviews with hospital managers and medical staff also pointed to the role of private health insurance companies in pressurizing hospitals to move towards day beds to save money. PFP hospitals are more subject to such pressures than public hospitals, with PNFP hospitals in between. Similarly, in terms of the Irish hospital classification, by 2015, 23.8% of private hospital beds were day beds, compared to 16.1% in public hospitals. Ireland’s privatization in international context Table 2 situates Ireland’s privatization experience in an international context. On one hand, privatization in Ireland has been real but less intense than in some other countries, with PFP hospitals accounting for 8.6% of inpatient beds in 2014. This is lower than countries like Germany (30.0%), France (23.7%) and Greece (32.8%), but higher than nations like Denmark (2.2%) and Finland (3.8%). Ireland was a relative latecomer to privatization, whose scale was still low in the 1990s, but grew relatively rapidly thereafter. Table 2 Percentage of total national inpatient beds by hospital type per country according to OECD statistics. 1995 2000 2005 2010 2014 Australia  Public 72.4 68.2 69.4 69.5  PNFP 13.4 14.2 14.2 14.3  PFP 14.2 17.6 16.4 16.2 Austria  Public 75.6 74.7 73.3 70.9 69.2  PNFP 17.4 18.2 17.7 18.0 17.4  PFP 7.0 7.2 9.0 11.1 13.5 Denmark  Public 99.2 95.9 95.5 93.8  PNFP 2.7 2.4 4.0  PFP 0.8 1.4 2.1 2.2 Finland  Public 96.7 96.7 96.3 95.6 96.2  PNFP 0.0 0.0 0.0 0.0 0.0  PFP 3.3 3.3 3.7 4.4 3.8 France  Public 65.6 65.4 62.5 62.4  PNFP 14.6 14.1 14.0 13.9  PFP 19.8 20.5 23.4 23.7 Germany  Public 43.4 40.6 40.7  PNFP 30.4 29.8 29.3  PFP 26.2 29.7 30.0 Greece  Public 69.4 69.6 68.8 65.3  PNFP 1.2 3.0 2.7 1.9  PFP 29.4 27.4 28.4 32.8 Irelanda  Public 47.6 51.8 52.9 49.8 49.3  PNFP 51.1 45.7 43.0 41.0 42.1  PFP 1.3 2.5 4.1 9.2 8.6 Portugal  Public 78.5 77.8 75.4 73.1 70.1  PNFP 17.3 17.1 18.7 18.3 19.7  PFP 4.2 5.1 6.0 8.6 10.2 Spain  Public 67.5 66.7 65.7 68.7 68.6  PNFP 13.0 15.4 14.6 13.1 12.5  PFP 19.5 18.0 19.7 18.2 18.9 United States  Public 30.1 26.3 25.5 24.5  PNFP 57.6 60.6 60.7 60.4  PFP 12.3 13.1 13.8 15.1 1995 2000 2005 2010 2014 Australia  Public 72.4 68.2 69.4 69.5  PNFP 13.4 14.2 14.2 14.3  PFP 14.2 17.6 16.4 16.2 Austria  Public 75.6 74.7 73.3 70.9 69.2  PNFP 17.4 18.2 17.7 18.0 17.4  PFP 7.0 7.2 9.0 11.1 13.5 Denmark  Public 99.2 95.9 95.5 93.8  PNFP 2.7 2.4 4.0  PFP 0.8 1.4 2.1 2.2 Finland  Public 96.7 96.7 96.3 95.6 96.2  PNFP 0.0 0.0 0.0 0.0 0.0  PFP 3.3 3.3 3.7 4.4 3.8 France  Public 65.6 65.4 62.5 62.4  PNFP 14.6 14.1 14.0 13.9  PFP 19.8 20.5 23.4 23.7 Germany  Public 43.4 40.6 40.7  PNFP 30.4 29.8 29.3  PFP 26.2 29.7 30.0 Greece  Public 69.4 69.6 68.8 65.3  PNFP 1.2 3.0 2.7 1.9  PFP 29.4 27.4 28.4 32.8 Irelanda  Public 47.6 51.8 52.9 49.8 49.3  PNFP 51.1 45.7 43.0 41.0 42.1  PFP 1.3 2.5 4.1 9.2 8.6 Portugal  Public 78.5 77.8 75.4 73.1 70.1  PNFP 17.3 17.1 18.7 18.3 19.7  PFP 4.2 5.1 6.0 8.6 10.2 Spain  Public 67.5 66.7 65.7 68.7 68.6  PNFP 13.0 15.4 14.6 13.1 12.5  PFP 19.5 18.0 19.7 18.2 18.9 United States  Public 30.1 26.3 25.5 24.5  PNFP 57.6 60.6 60.7 60.4  PFP 12.3 13.1 13.8 15.1 aFor Ireland, data refer to acute hospitals only, which account for ~90% of total hospital beds; data refer to a mix of bed capacity and availability (for details see table 1 notes). In general, OECD data for other countries refer to bed availability for all hospital types, although there are exceptions and a number of breaks in countries’ statistical series due to shifts in counting bed capacity or availability over time (e.g. Canada), inclusion or exclusion of certain hospitals, etc. For details, see Ref.25 View Large Table 2 Percentage of total national inpatient beds by hospital type per country according to OECD statistics. 1995 2000 2005 2010 2014 Australia  Public 72.4 68.2 69.4 69.5  PNFP 13.4 14.2 14.2 14.3  PFP 14.2 17.6 16.4 16.2 Austria  Public 75.6 74.7 73.3 70.9 69.2  PNFP 17.4 18.2 17.7 18.0 17.4  PFP 7.0 7.2 9.0 11.1 13.5 Denmark  Public 99.2 95.9 95.5 93.8  PNFP 2.7 2.4 4.0  PFP 0.8 1.4 2.1 2.2 Finland  Public 96.7 96.7 96.3 95.6 96.2  PNFP 0.0 0.0 0.0 0.0 0.0  PFP 3.3 3.3 3.7 4.4 3.8 France  Public 65.6 65.4 62.5 62.4  PNFP 14.6 14.1 14.0 13.9  PFP 19.8 20.5 23.4 23.7 Germany  Public 43.4 40.6 40.7  PNFP 30.4 29.8 29.3  PFP 26.2 29.7 30.0 Greece  Public 69.4 69.6 68.8 65.3  PNFP 1.2 3.0 2.7 1.9  PFP 29.4 27.4 28.4 32.8 Irelanda  Public 47.6 51.8 52.9 49.8 49.3  PNFP 51.1 45.7 43.0 41.0 42.1  PFP 1.3 2.5 4.1 9.2 8.6 Portugal  Public 78.5 77.8 75.4 73.1 70.1  PNFP 17.3 17.1 18.7 18.3 19.7  PFP 4.2 5.1 6.0 8.6 10.2 Spain  Public 67.5 66.7 65.7 68.7 68.6  PNFP 13.0 15.4 14.6 13.1 12.5  PFP 19.5 18.0 19.7 18.2 18.9 United States  Public 30.1 26.3 25.5 24.5  PNFP 57.6 60.6 60.7 60.4  PFP 12.3 13.1 13.8 15.1 1995 2000 2005 2010 2014 Australia  Public 72.4 68.2 69.4 69.5  PNFP 13.4 14.2 14.2 14.3  PFP 14.2 17.6 16.4 16.2 Austria  Public 75.6 74.7 73.3 70.9 69.2  PNFP 17.4 18.2 17.7 18.0 17.4  PFP 7.0 7.2 9.0 11.1 13.5 Denmark  Public 99.2 95.9 95.5 93.8  PNFP 2.7 2.4 4.0  PFP 0.8 1.4 2.1 2.2 Finland  Public 96.7 96.7 96.3 95.6 96.2  PNFP 0.0 0.0 0.0 0.0 0.0  PFP 3.3 3.3 3.7 4.4 3.8 France  Public 65.6 65.4 62.5 62.4  PNFP 14.6 14.1 14.0 13.9  PFP 19.8 20.5 23.4 23.7 Germany  Public 43.4 40.6 40.7  PNFP 30.4 29.8 29.3  PFP 26.2 29.7 30.0 Greece  Public 69.4 69.6 68.8 65.3  PNFP 1.2 3.0 2.7 1.9  PFP 29.4 27.4 28.4 32.8 Irelanda  Public 47.6 51.8 52.9 49.8 49.3  PNFP 51.1 45.7 43.0 41.0 42.1  PFP 1.3 2.5 4.1 9.2 8.6 Portugal  Public 78.5 77.8 75.4 73.1 70.1  PNFP 17.3 17.1 18.7 18.3 19.7  PFP 4.2 5.1 6.0 8.6 10.2 Spain  Public 67.5 66.7 65.7 68.7 68.6  PNFP 13.0 15.4 14.6 13.1 12.5  PFP 19.5 18.0 19.7 18.2 18.9 United States  Public 30.1 26.3 25.5 24.5  PNFP 57.6 60.6 60.7 60.4  PFP 12.3 13.1 13.8 15.1 aFor Ireland, data refer to acute hospitals only, which account for ~90% of total hospital beds; data refer to a mix of bed capacity and availability (for details see table 1 notes). In general, OECD data for other countries refer to bed availability for all hospital types, although there are exceptions and a number of breaks in countries’ statistical series due to shifts in counting bed capacity or availability over time (e.g. Canada), inclusion or exclusion of certain hospitals, etc. For details, see Ref.25 View Large On the other hand, Ireland’s hospital sector can still be described as highly private because PFP and PNFP hospitals account for half (50.7%) the national bed stock, with public hospitals accounting for 49.3%. But even countries with a more developed PFP sector have kept a higher proportion of their beds under public ownership, such as France (62.4%) Spain (68.6%) and Austria (69.2%). The difference is explained by Ireland’s relatively large number of beds in PNFP hospitals, established by the Catholic Church, Protestant churches and charities.24 Discussion Main findings of this study This study presents an examination of trends in bed supply over time in Ireland, focusing on privatization within the context of government policy on bed provision. Figure 1 and Table 1 suggest the following trends from 1980 to 2015. Overall, the number of inpatient beds decreased significantly. The number of PFP beds rose from 0 to 1075, inpatient beds were nearly halved in PNFP hospitals, from 9601 to 5216, and decreased from 7028 to 6092 in public hospitals. Also, by 2015, 24.1% of PFP hospital beds were day beds, compared to 17.7% for PNFP and 15.7% for public hospitals. In the Irish classification, between 1980 and 2015, inpatient beds dropped from 15 111 to 10 473 in public hospitals but increased from 1518 to 1910 in private hospitals; by 2015, 23.8% of private hospital beds were day beds, compared to 16.1% in public hospitals. What is already known on this topic It is known that the number of private acute hospitals has grown in Ireland over the last several decades and that similar privatization trends have characterized many other countries. It is also known that technological advances and cost pressures have led hospitals to utilize more day beds. What this study adds This study presents the annual number of private hospital beds in Ireland since 1980 for the first time, together with international comparisons. The differences in the evolution of day and inpatient beds by hospital type have been described. Also, this study presents a reclassification of Irish acute hospitals according to international norms, facilitating comparative international research. Limitations of the study This study’s private hospital data were collected via direct requests to hospitals and complemented by other sources such as the Irish Medical Directory. Ideally, these data should have been collected by the Irish government through an appropriate systematic data collection process. Unfortunately, this is not done for private hospitals. Retrospective direct data requests to hospitals involve potential data quality losses, as discussed above. Conclusion Privatization has transformed health care systems worldwide. Since the 1980s, the Irish government has supported for-profit hospital care. Thus, PFP hospitals have grown over the last three decades. Conversely, the public hospital system has been neglected. In particular, during two periods of austerity in the 1980s and in the years after the 2008 financial crisis, a number public and PNFP beds were eliminated. Public hospitals have thus had difficulty meeting the demand for care and long waiting lists have become an acute national problem. Supplementary data Supplementary data are available at the Journal of Public Health online. Acknowledgements The author would like to thank two anonymous reviewers who provided very insightful and constructive comments that have strengthened the article considerably. Many thanks are also due to former and current officials in private hospitals and health insurance companies as well as analysts in the Department of Health and Health Service Executive who have supplied data to the author. References 1 Wren M-A . Unhealthy State: Anatomy of a Sick Society . Dublin : New Island , 2003 . 2 Turner B . Unwinding the State subsidisation of private health insurance in Ireland . Health Policy 2015 ; 119 : 1349 – 57 . Google Scholar CrossRef Search ADS PubMed 3 Connolly S , Wren M-A . The 2011 proposal for Universal Health Insurance in Ireland: potential implications for healthcare expenditure . Health Policy 2016 ; 120 : 790 – 6 . Google Scholar CrossRef Search ADS PubMed 4 OECD . Health Statistics. Paris: OECD, 2017. http://stats.oecd.org/ (4 August 2017, date last accessed). 5 Department of Health . Health in Ireland, Key Trends 2015. Dublin: Department of Health, 2015. 6 Thomas S , Burke S , Barry S . The Irish health-care system and austerity: sharing the pain . Lancet 2014 ; 383 : 1545 – 6 . Google Scholar CrossRef Search ADS PubMed 7 Burger J. Jimmy Sheehan’s mission to heal. Legatus. 2013 http://legatus.org/jimmy-sheehans-mission-to-heal/ (12 January 2018, date last accessed). 8 Tussing AD , Wren M-A . How Ireland Cares: The Case for Health Care Reform . Dublin : New Island , 2006 . 9 André C , Hermann C . Privatisation and marketisation of health care systems in Europe. In: Frangakis M , Hermann C , Huffschmid J , Lorant K (eds) . Privatisation Against the European Social Model . London : Palgrave Macmillan , 2009 : 129 – 44 . Google Scholar CrossRef Search ADS 10 Department of Health . Health Statistics . Dublin : Department of Health , various years. 11 Eurostat . Definitions and data collection specifications on health care statistics (non-expenditure data). 10 July 2016. https://circabc.europa.eu/d/a/workspace/SpacesStore/3a37b5c6-2b85-4bc2-a254-06e0976355a5/ESTAT-OECD-definitions-CARE-non-expenditure%20(09.07.2010).pdf (12 January 2018, date last accessed). 12 Nolte E , Pitchforth E , Miani C et al. . The changing hospital landscape: an exploration of international experiences . Rand Health Q 2014 ; 4 : 1 . 13 Healthcare Pricing Office . Activity in Acute Public Hospitals in Ireland Annual Report . Dublin : Health Service Executive various years . 14 OECD, Eurostat, WHO . A System of Health Accounts. Paris: OECD. 15 Department of Health . Health Statistics 1993 Prepared by Information Management Unit, Department of Health . Dublin : Department of Health , 1993 . 16 Guéret M . Irish Medical Directory: The Directory of Irish Healthcare . Dublin : Irish Medical Directory , various years. 17 Vision-net. https://www.vision-net.ie/ (12 January 2018, date last accessed). 18 Department of Health . Personal Communication (Email). Email from Department of Health Official to Julien Mercille. 2017 . 19 Department of Health . Health in Ireland, Key Trends 2017 . Dublin : Department of Health , 2017 . 20 Health Service Executive . National Service Plan 2006 . Dublin : Health Service Executive , 2005 . 21 Central Statistics Office . Population. Dublin: Central Statistics Office, 2017 . http://www.cso.ie/en/statistics/population/ (12 January 2018, date last accessed). 22 Brick A , Nolan A , O’Reilly J et al. . Resource Allocation, Financing and Sustainability in Health Care . Dublin : Economic and Social Research Institute , July 2010 . 23 Eurostat . Hospital Discharges and Length of Stay Statistics. 2016. http://ec.europa.eu/eurostat/statistics-explained/index.php/Hospital_discharges_and_length_of_stay_statistics (12 January 2018, date last accessed). 24 Barrington R . Health, Medicine and Politics in Ireland 1900–1970 . Dublin : Institute of Public Administration , 1987 . 25 OECD . OECD Health Statistics 2017: Definitions, Sources and Methods: Hospital Beds . Paris : OECD , 2017 . © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

Privatization in the Irish hospital sector since 1980

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Abstract

Abstract Background Privatization has transformed health care systems over the last several decades. This article examines trends in bed supply in Ireland between 1980 and 2015 within the context of government policy on bed provision in a system of inequitable access to care. Ireland has not published bed data on private hospitals since the 1980s, even if they comprise about one-quarter of all hospitals. However, this article presents, for the first time, annual bed data since the 1980s collected from private hospitals and used to trace the evolution of bed supply over time. Methods Bed data were collected for private Irish hospitals for the years 1980–2015, mainly through direct requests to hospitals. Additional sources included the Irish Medical Directory, private health insurance data, hospital company records and newspaper archives. Results Subject to data caveats explained in the article, between 1980 and 2015, total inpatient beds decreased by 25.5% nationally. Inpatient bed numbers in private for-profit (PFP) hospitals rose from 0 to 1075 but decreased from 9601 to 5216 in private not-for-profit (PNFP) hospitals and from 7028 to 6092 in public hospitals (using the Irish hospital classification, beds in private hospitals increased from 1518 to 1910 but decreased from 15 111 to 10 473 in public hospitals). Also, by 2015, 24.1% of PFP hospital beds were day beds, compared to 17.7% for PNFP and 15.7% for public hospitals (using the Irish classification, by 2015, day beds accounted for 23.8% of beds in private hospitals and 16.1% in public hospitals). Conclusions Trends in bed supply in Ireland between 1980 and 2015 are documented empirically for all Irish acute hospitals and contextualized within government policy on bed provision. The Irish acute hospital system has experienced privatization reforms supported by the government over the last several decades. health systems, hospitals, Ireland, marketization, privatization Introduction Ireland has a mixed public–private system of hospital care. Health Service Executive (HSE) hospitals are publicly owned and funded, so-called voluntary hospitals are publicly funded but owned by religious or lay trusts, and so-called private hospitals are owned and funded privately. The development of a public system comparable to Britain’s NHS was obstructed historically by political and economic elites, the Catholic Church and the medical professions opposed to the ‘socialisation of medicine’ (p. 32 in Ref.1). Since the 1980s, government policy has supported the growth of for-profit care in the hospital system in several ways. First, publicly employed consultants (specialized doctors) have been allowed to engage in private practice in both public and private hospitals, so that they have traditionally privileged private patients, maintaining a two-tier health system. However, since 2008, new contracts have included incentives to treat more public patients.2,3 Second, private health insurance is subsidized by the state. Nearly half the population have private insurance and can claim tax exemptions on insurance costs. The cost of this to the state was €448 million in 2012.2 Moreover, the cost charged to private insurers for accommodation of patients in public hospitals remains below the full economic cost.2 Third, two periods of austerity, in the 1980s and following the 2008 financial crisis, have squeezed the public system, resulting in lengthening waiting lists. From 1980 to 1989, real public health spending was cut by 7.5%, including a 9.7% cut in the general hospital program between 1985 and 19894 (Ref.4 and Table A.2 in Ref.1). Between 2008 and 2014, current public health expenditure decreased by 10.0%, including a decrease of 27.8% in capital spending on acute hospitals (Tables 6.1 and 6.3 in Refs.5,6). Between those two periods of austerity, however, real public health spending increased significantly, quadrupling between 1990 and 2008, in the context of Ireland’s rapid economic expansion.4 The reduced involvement of the state in health care opened the door to the for-profit sector. Reflecting on his time as Minister for Health in the early 1990s, Brendan Howlin (Labour Party) explained how he came to understand that maintaining a public health system of inferior quality was implicit in government support for private health insurance. He said: ‘The government wanted a chunk of the population—30% or thereabouts—to pay for private health insurance but, in order for that to happen, they really required the public system to be inferior. Why else, if it was first rate, would people pay for a private system?’ (p. 99 in Ref.1). Moreover, Jimmy Sheehan, the founder of Blackrock Clinic—Ireland’s best-known private for-profit (PFP) hospital—explained how health cuts led to the rise of PFP hospitals in the 1980s: the country faced ‘very considerable waiting lists for artificial joint surgery, as well as other high-tech areas such as open heart surgery’ due to health care rationing. ‘As a practicing surgeon I was frustrated with the lack of facilities, and it was that frustration that led to the development of Blackrock’.7 Fourth, between 2002 and 2010, the government implemented a program of tax incentives for investors in PFP hospitals, which boosted construction. For every €100 million in hospital construction, the government offered €44 million in tax breaks to investors (pp. 361–2 in Ref.8). Moreover, the National Treatment Purchase Fund was established in 2005, which allowed the government to pay PFP hospitals to treat patients on public waiting lists. Such incentives resulted in a mushrooming of PFP hospitals. The growth of the private sector in the Irish hospital system fits within the privatization trends witnessed in health care systems globally since the 1980s.9 This article examines trends in bed supply over time in Ireland’s acute hospital sector, which accounts for ~90% of total hospital beds in the country. Unfortunately, the Irish government has not compiled and published statistics for PFP hospitals and for a significant number of private not-for-profit (PNFP) hospitals since the 1980s. Reference databases (OECD, Eurostat, WHO) thus indicate ‘no data available’ for a number of key indicators. On the other hand, official Irish hospital statistics do exist for all public and some PNFP hospitals.10 However, these existing data are difficult to compare with other countries’ statistics because the Irish hospital classification system does not follow international norms that categorize hospitals into public, PNFP and PFP based on ownership.11 Thus, this article additionally presents a reclassification of Irish hospitals according to international standards and presents hospital data using both schemes so that readers familiar with either can interpret the data more easily. The absence of Irish private hospital data and idiosyncratic classification system has misled secondary research. For example, a RAND Corporation report on privatization trends in the hospital sector in four countries (Ireland, France, Germany, United States) suggested that there is no trend toward privatization in Ireland, which is not accurate. It stated: ‘We have observed an increasing trend towards hospital privatization and consolidation in three of the countries reviewed, France, Germany and the United States’.12 However, given the gaps in the data they were relying on for their analysis, their conclusion is understandable—OECD and Irish government data contain no information on PFP hospitals. Other work suffers from similar shortcomings. Ireland’s HSE publishes an annual in-depth analysis of the hospital sector.13 Yet, it is based exclusively on publicly funded hospitals, excluding PFP and many PNFP hospitals. It is thus difficult to paint a comprehensive picture of the Irish hospital sector and examine trends and developments within it precisely. Methods Reclassification of Irish hospitals This article is concerned with Irish acute hospitals. These comprise nearly all general and specialized hospitals (HP.1.1 and HP.1.3, in OECD-Eurostat-WHO coding).14 Mental health hospitals (HP.1.2), which account for ~10% of total hospital beds in Ireland, are excluded. It would be difficult to compile data on mental health hospitals because before 2009, mental health facilities were not differentiated into hospitals (HP.1.2) and non-hospitals (HP.2.2). In the Irish system, hospitals are classified as ‘public’ or ‘private’ whether their main funding source is public or private. The OECD-Eurostat-WHO methodology classifies hospitals differently, into public, PNFP and PFP according to criteria of ownership, corporate governance and revenue distribution. Public hospitals are those ‘owned or controlled by a government unit’, PNFP hospitals are not permitted ‘to be a source of income, profit, or other financial gain’ for their owners or those who control them, and PFP hospitals ‘are capable of generating a profit or other financial gain for their owners’ (p. 31 in Ref.11). All hospitals were reclassified following OECD-Eurostat-WHO norms.14 All ‘public non-voluntary’ hospitals in the Irish scheme were reclassified as ‘public’. All ‘public voluntary’ hospitals were reclassified as PNFP because they are controlled by entities other than government units. Private hospitals in the Irish classification were reclassified either as PNFP if their revenues are not distributed to their owners, or as PFP if their revenues are distributed to their owners (essentially, religious-owned hospitals were classified as PNFP and investors-owned hospitals as PFP). When hospitals changed their status at any point in time, their categorization was adjusted accordingly. Bed data Inpatient and day bed data were compiled for all acute hospitals in the country between 1980 and 2015. Inpatient beds are beds in which patients spend at least one night while day beds do not involve an overnight stay. Data were obtained differently for publicly and privately funded hospitals. First, the Department of Health publishes bed data for all publicly funded hospitals (i.e. all public hospitals and a number of PNFP ones). These data were used with one modification: district hospital beds were excluded for all years (official statistics did include district hospitals in 1980–91). Another issue should be noted: in 1980–92, it is the bed capacity that was recorded by the Department of Heath, namely, the number of physical beds in hospitals; since 1993, the number of available beds has been recorded, namely, beds that are staffed and ready to be used (Table G1 in Ref.15). Second, there are no published data on hospitals funded privately (i.e. all PFP and some PNFP hospitals) and these had to be collected—except for 1980–84, when the Department of Health did collect these data (bed capacity), used for this article. For 1984–2015, data were gathered via direct inquiries to hospital managers, bed managers and directors of nursing in undocumented private hospitals, as well as to religious orders that own hospitals. Inquiries were made both by email and by telephone both to current and past officers in every hospital (see Supplemental Table S1 for detailed data and sources). These data were complemented by the Irish Medical Directory,16 which has listed some bed numbers annually for some hospitals since 1993. Additional sources used to complete and confirm the data included the following: requests to Vhi Healthcare (the largest health insurance company in Ireland), local and national newspaper archives for mentions of bed numbers and hospital openings and closures (including ads placed by hospitals mentioning bed numbers), and hospital constitutions and annual reports.17 There are limitations to these data collected from private hospitals. First, they refer to bed capacity (the number of available beds could not be obtained because it requires data unavailable or lost by private hospitals, such as the daily number of staffed beds). They are thus directly comparable to official data for publicly funded hospitals in 1980–92 (which also refer to bed capacity). However, for 1993–2015, the Department of Health reports available beds for public hospitals, not directly comparable with bed capacity in private hospitals. But fortunately, in public hospitals, the difference between bed capacity and availability is small: <8% in 2016 and smaller in earlier years—2% in 1993 and 4% in 2005, for example—for both inpatient and day beds. (These percentages are calculated as follows. For 2016, national total bed capacity for publicly funded hospitals was 11 426 inpatient beds and 2234 day beds18 while bed availability was 10 592 inpatient and 2140 day beds (Table 3.1A, p. 36 in Ref.19)—a difference of <8% between inpatient beds available and bed capacity. In 2005, the difference was ~4%: 12 094 inpatient and 1253 day beds available (Table 1) versus 12 574 inpatient and 1197 day beds capacity (p. 65 in Ref.20) In 1993, the difference was less than 2% for inpatient beds (11 809 available and 12 000 capacity) (Table G1, p. 77 in Ref.15)). On the other hand, in private hospitals, there is a larger gap between bed availability and capacity (though no precise data are available). In sum, public and private hospitals’ bed numbers are more comparable in terms of bed capacity than bed availability. Second, data quality depends on hospital officers’ answers: for example, imprecise recall and deaths of officers in charge of bed management in past decades may all affect quality. Nevertheless, officers all had a direct role in bed management (they were hospital CEOs, bed managers, nursing directors, financial officers) and bed capacity is relatively easy to remember because it tends to remain stable except when major works are conducted in the hospital (opening or closing wards). As much as possible, data provided by one officer were cross-checked with another source. Results Trends in bed supply in the Irish hospital sector are shown in Fig. 1 and Table 1. Between 1980 and 2015, the total number of inpatient beds decreased by 25.5%, from 16 629 to 12 383. (The total number of beds in 1980 (16 629) refers to bed capacity, but the number of beds for 2015 (12 383) refers to available beds in publicly funded hospitals and bed capacity in privately funded hospitals. The 25.5% drop is thus subject to this caveat.) During this period, the country’s population rose from 3.4 to 4.7 millions,21 resulting in a decline in beds per capita from 4.89 to 2.63 beds per 1000 inhabitants. Table 1 Number of hospitals and beds in Ireland (international and Irish classifications), 1980–2015. Year International classification Totald Irish classification Publica Private for-profitb Private not-for-profitc Publice Privatef IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals 1980 7028 0 43 0 0 0 9601 36 60 16 629 36 103 15 111 36 87 1518 0 16 1981 7085 0 43 0 0 0 9543 26 58 16 628 26 101 15 093 26 85 1535 0 16 1982 7108 0 42 0 0 0 9496 26 58 16 604 26 100 15 106 26 84 1498 0 16 1983 7105 0 42 0 0 0 9573 0 58 16 678 0 100 15 163 0 84 1515 0 16 1984 7103 0 42 0 0 0 9309 17 57 16 412 17 99 14 890 13 83 1522 4 16 1985 7214 12 40 8 8 1 9202 25 56 16 424 45 97 14 898 25 80 1526 20 17 1986 7214 12 39 155 14 3 8874 55 54 16 243 81 96 14 583 49 79 1660 32 17 1987 6365 39 36 180 14 3 8199 44 51 14 744 97 90 13 078 53 74 1666 44 16 1988 6170 78 36 180 14 3 7015 166 43 13 365 258 82 11 726 207 66 1639 51 16 1989 6138 153 36 180 14 3 7087 214 40 13 405 381 79 11 766 324 63 1639 57 16 1990 6314 138 36 180 30 3 7091 202 41 13 585 370 80 11 912 284 63 1673 86 17 1991 6311 170 36 180 30 3 7161 258 41 13 652 458 80 11 979 368 63 1673 90 17 1992 6560 172 36 180 30 3 7064 363 41 13 804 565 80 12 136 462 63 1668 103 17 1993 6358 195 37 180 30 3 6939 398 40 13 477 623 80 11 809 516 63 1668 107 17 1994 6392 208 36 180 30 3 6950 390 41 13 522 628 80 11 853 521 63 1669 107 17 1995 6488 212 36 180 30 3 6974 426 41 13 642 668 80 11 953 543 63 1689 125 17 1996 6537 245 36 180 30 3 6849 429 39 13 566 704 78 11 937 583 62 1629 121 16 1997 6828 282 37 249 30 4 6363 421 37 13 440 733 78 11 861 612 62 1579 121 16 1998 6817 287 37 249 30 4 6267 462 34 13 333 779 75 11 788 636 60 1545 143 15 1999 6865 312 37 184 30 3 6278 487 35 13 327 829 75 11 781 673 60 1546 156 15 2000 6920 357 37 335 36 4 6116 485 34 13 371 878 75 11 891 721 60 1480 157 15 2001 7154 386 38 367 79 5 6027 516 33 13 548 981 76 12 036 771 60 1512 210 16 2002 7289 403 38 377 85 5 5997 532 30 13 663 1020 73 12 264 812 60 1399 208 13 2003 7350 492 37 409 85 6 5945 559 29 13 704 1136 72 12 299 909 59 1405 227 13 2004 7169 595 35 556 116 8 5714 679 25 13 439 1390 68 11 887 1132 53 1552 258 15 2005 7232 699 35 556 123 8 5880 724 26 13 668 1546 69 12 094 1253 54 1574 293 15 2006 7196 788 35 921 245 12 5780 810 24 13 897 1843 71 12 110 1418 53 1787 425 18 2007 7300 872 34 958 266 13 5688 856 24 13 946 1994 71 12 121 1545 52 1825 449 19 2008 7082 934 34 1015 276 13 5620 995 24 13 717 2205 71 11 847 1737 52 1870 468 19 2009 6822 985 33 1015 303 13 5571 979 24 13 408 2267 70 11 538 1772 51 1870 495 19 2010 6560 1019 32 1210 315 14 5407 1053 23 13 177 2387 69 11 159 1834 50 2018 553 19 2011 6358 1069 32 1214 309 14 5333 1090 23 12 905 2468 69 10 849 1913 50 2056 555 19 2012 6131 1101 31 1214 313 14 5203 1171 23 12 548 2585 68 10 492 2026 49 2056 559 19 2013 5995 1143 31 1214 341 14 5258 1101 23 12 467 2585 68 10 411 1998 49 2056 587 19 2014 6111 1135 31 1064 331 13 5211 1096 24 12 386 2562 68 10 480 1983 50 1906 579 18 2015 6092 1137 31 1075 341 13 5216 1121 24 12 383 2599 68 10 473 2003 50 1910 596 18 Year International classification Totald Irish classification Publica Private for-profitb Private not-for-profitc Publice Privatef IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals 1980 7028 0 43 0 0 0 9601 36 60 16 629 36 103 15 111 36 87 1518 0 16 1981 7085 0 43 0 0 0 9543 26 58 16 628 26 101 15 093 26 85 1535 0 16 1982 7108 0 42 0 0 0 9496 26 58 16 604 26 100 15 106 26 84 1498 0 16 1983 7105 0 42 0 0 0 9573 0 58 16 678 0 100 15 163 0 84 1515 0 16 1984 7103 0 42 0 0 0 9309 17 57 16 412 17 99 14 890 13 83 1522 4 16 1985 7214 12 40 8 8 1 9202 25 56 16 424 45 97 14 898 25 80 1526 20 17 1986 7214 12 39 155 14 3 8874 55 54 16 243 81 96 14 583 49 79 1660 32 17 1987 6365 39 36 180 14 3 8199 44 51 14 744 97 90 13 078 53 74 1666 44 16 1988 6170 78 36 180 14 3 7015 166 43 13 365 258 82 11 726 207 66 1639 51 16 1989 6138 153 36 180 14 3 7087 214 40 13 405 381 79 11 766 324 63 1639 57 16 1990 6314 138 36 180 30 3 7091 202 41 13 585 370 80 11 912 284 63 1673 86 17 1991 6311 170 36 180 30 3 7161 258 41 13 652 458 80 11 979 368 63 1673 90 17 1992 6560 172 36 180 30 3 7064 363 41 13 804 565 80 12 136 462 63 1668 103 17 1993 6358 195 37 180 30 3 6939 398 40 13 477 623 80 11 809 516 63 1668 107 17 1994 6392 208 36 180 30 3 6950 390 41 13 522 628 80 11 853 521 63 1669 107 17 1995 6488 212 36 180 30 3 6974 426 41 13 642 668 80 11 953 543 63 1689 125 17 1996 6537 245 36 180 30 3 6849 429 39 13 566 704 78 11 937 583 62 1629 121 16 1997 6828 282 37 249 30 4 6363 421 37 13 440 733 78 11 861 612 62 1579 121 16 1998 6817 287 37 249 30 4 6267 462 34 13 333 779 75 11 788 636 60 1545 143 15 1999 6865 312 37 184 30 3 6278 487 35 13 327 829 75 11 781 673 60 1546 156 15 2000 6920 357 37 335 36 4 6116 485 34 13 371 878 75 11 891 721 60 1480 157 15 2001 7154 386 38 367 79 5 6027 516 33 13 548 981 76 12 036 771 60 1512 210 16 2002 7289 403 38 377 85 5 5997 532 30 13 663 1020 73 12 264 812 60 1399 208 13 2003 7350 492 37 409 85 6 5945 559 29 13 704 1136 72 12 299 909 59 1405 227 13 2004 7169 595 35 556 116 8 5714 679 25 13 439 1390 68 11 887 1132 53 1552 258 15 2005 7232 699 35 556 123 8 5880 724 26 13 668 1546 69 12 094 1253 54 1574 293 15 2006 7196 788 35 921 245 12 5780 810 24 13 897 1843 71 12 110 1418 53 1787 425 18 2007 7300 872 34 958 266 13 5688 856 24 13 946 1994 71 12 121 1545 52 1825 449 19 2008 7082 934 34 1015 276 13 5620 995 24 13 717 2205 71 11 847 1737 52 1870 468 19 2009 6822 985 33 1015 303 13 5571 979 24 13 408 2267 70 11 538 1772 51 1870 495 19 2010 6560 1019 32 1210 315 14 5407 1053 23 13 177 2387 69 11 159 1834 50 2018 553 19 2011 6358 1069 32 1214 309 14 5333 1090 23 12 905 2468 69 10 849 1913 50 2056 555 19 2012 6131 1101 31 1214 313 14 5203 1171 23 12 548 2585 68 10 492 2026 49 2056 559 19 2013 5995 1143 31 1214 341 14 5258 1101 23 12 467 2585 68 10 411 1998 49 2056 587 19 2014 6111 1135 31 1064 331 13 5211 1096 24 12 386 2562 68 10 480 1983 50 1906 579 18 2015 6092 1137 31 1075 341 13 5216 1121 24 12 383 2599 68 10 473 2003 50 1910 596 18 Notes: Data in both the international and Irish classifications sum to the total column. IP, inpatient beds; D, day beds. aIP and D bed numbers refer to bed capacity (1980–92) and bed availability (1993–2015). bIP and D bed numbers refer to bed capacity (1980–2015). cIP and D bed numbers refer to bed capacity (1980–92) and a combination of bed capacity and availability (1993–2015) (the combination results from the aggregation of public voluntary beds (measured in bed availability) in the Irish classification and private not-for-profit beds (measured in bed capacity) among private hospitals in the Irish classification). dIP and D bed numbers refer to bed capacity (1980–92) and a combination of bed capacity and availability (1993–2015). eIP and D bed numbers refer to bed capacity (1980–92) and bed availability (1993–2015). fIP and D bed numbers refer to bed capacity (1980–2015). Data sources 1. Privately funded hospitals (private for-profit, some private not-for-profit, private (Irish classification)): Table S1 2. Publicly funded hospitals (public, some private not-for-profit, public (Irish classification)): Department of Health’s annual statistics series.15,19 However, this article excludes district hospitals for all years (the Department of Health included district hospitals in its data for 1980–91). Also, because the Health in Ireland: Key Trends series20 does not provide a breakdown of bed numbers by hospital, the Department of Health supplied these data to the author for 2011–15. To distinguish public voluntary and non-voluntary hospitals, for 1980–2003 data, voluntary and HSE/Health Boards hospitals are distinguished in Department of Health statistics and this classification was followed; but for 2004–15, hospitals are not distinguished in such a way in the published data, therefore, the annual Activity in Acute Public Hospitals in Ireland series13 was used (its Appendix I lists and classifies hospitals into voluntary and non-voluntary). Also, this article excludes Monaghan General Hospital’s 23 D beds in 2010–15 because it had no IP beds left, whereas Department of Health Statistics still counted its 23 D beds for those years. Table 1 Number of hospitals and beds in Ireland (international and Irish classifications), 1980–2015. Year International classification Totald Irish classification Publica Private for-profitb Private not-for-profitc Publice Privatef IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals 1980 7028 0 43 0 0 0 9601 36 60 16 629 36 103 15 111 36 87 1518 0 16 1981 7085 0 43 0 0 0 9543 26 58 16 628 26 101 15 093 26 85 1535 0 16 1982 7108 0 42 0 0 0 9496 26 58 16 604 26 100 15 106 26 84 1498 0 16 1983 7105 0 42 0 0 0 9573 0 58 16 678 0 100 15 163 0 84 1515 0 16 1984 7103 0 42 0 0 0 9309 17 57 16 412 17 99 14 890 13 83 1522 4 16 1985 7214 12 40 8 8 1 9202 25 56 16 424 45 97 14 898 25 80 1526 20 17 1986 7214 12 39 155 14 3 8874 55 54 16 243 81 96 14 583 49 79 1660 32 17 1987 6365 39 36 180 14 3 8199 44 51 14 744 97 90 13 078 53 74 1666 44 16 1988 6170 78 36 180 14 3 7015 166 43 13 365 258 82 11 726 207 66 1639 51 16 1989 6138 153 36 180 14 3 7087 214 40 13 405 381 79 11 766 324 63 1639 57 16 1990 6314 138 36 180 30 3 7091 202 41 13 585 370 80 11 912 284 63 1673 86 17 1991 6311 170 36 180 30 3 7161 258 41 13 652 458 80 11 979 368 63 1673 90 17 1992 6560 172 36 180 30 3 7064 363 41 13 804 565 80 12 136 462 63 1668 103 17 1993 6358 195 37 180 30 3 6939 398 40 13 477 623 80 11 809 516 63 1668 107 17 1994 6392 208 36 180 30 3 6950 390 41 13 522 628 80 11 853 521 63 1669 107 17 1995 6488 212 36 180 30 3 6974 426 41 13 642 668 80 11 953 543 63 1689 125 17 1996 6537 245 36 180 30 3 6849 429 39 13 566 704 78 11 937 583 62 1629 121 16 1997 6828 282 37 249 30 4 6363 421 37 13 440 733 78 11 861 612 62 1579 121 16 1998 6817 287 37 249 30 4 6267 462 34 13 333 779 75 11 788 636 60 1545 143 15 1999 6865 312 37 184 30 3 6278 487 35 13 327 829 75 11 781 673 60 1546 156 15 2000 6920 357 37 335 36 4 6116 485 34 13 371 878 75 11 891 721 60 1480 157 15 2001 7154 386 38 367 79 5 6027 516 33 13 548 981 76 12 036 771 60 1512 210 16 2002 7289 403 38 377 85 5 5997 532 30 13 663 1020 73 12 264 812 60 1399 208 13 2003 7350 492 37 409 85 6 5945 559 29 13 704 1136 72 12 299 909 59 1405 227 13 2004 7169 595 35 556 116 8 5714 679 25 13 439 1390 68 11 887 1132 53 1552 258 15 2005 7232 699 35 556 123 8 5880 724 26 13 668 1546 69 12 094 1253 54 1574 293 15 2006 7196 788 35 921 245 12 5780 810 24 13 897 1843 71 12 110 1418 53 1787 425 18 2007 7300 872 34 958 266 13 5688 856 24 13 946 1994 71 12 121 1545 52 1825 449 19 2008 7082 934 34 1015 276 13 5620 995 24 13 717 2205 71 11 847 1737 52 1870 468 19 2009 6822 985 33 1015 303 13 5571 979 24 13 408 2267 70 11 538 1772 51 1870 495 19 2010 6560 1019 32 1210 315 14 5407 1053 23 13 177 2387 69 11 159 1834 50 2018 553 19 2011 6358 1069 32 1214 309 14 5333 1090 23 12 905 2468 69 10 849 1913 50 2056 555 19 2012 6131 1101 31 1214 313 14 5203 1171 23 12 548 2585 68 10 492 2026 49 2056 559 19 2013 5995 1143 31 1214 341 14 5258 1101 23 12 467 2585 68 10 411 1998 49 2056 587 19 2014 6111 1135 31 1064 331 13 5211 1096 24 12 386 2562 68 10 480 1983 50 1906 579 18 2015 6092 1137 31 1075 341 13 5216 1121 24 12 383 2599 68 10 473 2003 50 1910 596 18 Year International classification Totald Irish classification Publica Private for-profitb Private not-for-profitc Publice Privatef IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals IP beds D beds Hospitals 1980 7028 0 43 0 0 0 9601 36 60 16 629 36 103 15 111 36 87 1518 0 16 1981 7085 0 43 0 0 0 9543 26 58 16 628 26 101 15 093 26 85 1535 0 16 1982 7108 0 42 0 0 0 9496 26 58 16 604 26 100 15 106 26 84 1498 0 16 1983 7105 0 42 0 0 0 9573 0 58 16 678 0 100 15 163 0 84 1515 0 16 1984 7103 0 42 0 0 0 9309 17 57 16 412 17 99 14 890 13 83 1522 4 16 1985 7214 12 40 8 8 1 9202 25 56 16 424 45 97 14 898 25 80 1526 20 17 1986 7214 12 39 155 14 3 8874 55 54 16 243 81 96 14 583 49 79 1660 32 17 1987 6365 39 36 180 14 3 8199 44 51 14 744 97 90 13 078 53 74 1666 44 16 1988 6170 78 36 180 14 3 7015 166 43 13 365 258 82 11 726 207 66 1639 51 16 1989 6138 153 36 180 14 3 7087 214 40 13 405 381 79 11 766 324 63 1639 57 16 1990 6314 138 36 180 30 3 7091 202 41 13 585 370 80 11 912 284 63 1673 86 17 1991 6311 170 36 180 30 3 7161 258 41 13 652 458 80 11 979 368 63 1673 90 17 1992 6560 172 36 180 30 3 7064 363 41 13 804 565 80 12 136 462 63 1668 103 17 1993 6358 195 37 180 30 3 6939 398 40 13 477 623 80 11 809 516 63 1668 107 17 1994 6392 208 36 180 30 3 6950 390 41 13 522 628 80 11 853 521 63 1669 107 17 1995 6488 212 36 180 30 3 6974 426 41 13 642 668 80 11 953 543 63 1689 125 17 1996 6537 245 36 180 30 3 6849 429 39 13 566 704 78 11 937 583 62 1629 121 16 1997 6828 282 37 249 30 4 6363 421 37 13 440 733 78 11 861 612 62 1579 121 16 1998 6817 287 37 249 30 4 6267 462 34 13 333 779 75 11 788 636 60 1545 143 15 1999 6865 312 37 184 30 3 6278 487 35 13 327 829 75 11 781 673 60 1546 156 15 2000 6920 357 37 335 36 4 6116 485 34 13 371 878 75 11 891 721 60 1480 157 15 2001 7154 386 38 367 79 5 6027 516 33 13 548 981 76 12 036 771 60 1512 210 16 2002 7289 403 38 377 85 5 5997 532 30 13 663 1020 73 12 264 812 60 1399 208 13 2003 7350 492 37 409 85 6 5945 559 29 13 704 1136 72 12 299 909 59 1405 227 13 2004 7169 595 35 556 116 8 5714 679 25 13 439 1390 68 11 887 1132 53 1552 258 15 2005 7232 699 35 556 123 8 5880 724 26 13 668 1546 69 12 094 1253 54 1574 293 15 2006 7196 788 35 921 245 12 5780 810 24 13 897 1843 71 12 110 1418 53 1787 425 18 2007 7300 872 34 958 266 13 5688 856 24 13 946 1994 71 12 121 1545 52 1825 449 19 2008 7082 934 34 1015 276 13 5620 995 24 13 717 2205 71 11 847 1737 52 1870 468 19 2009 6822 985 33 1015 303 13 5571 979 24 13 408 2267 70 11 538 1772 51 1870 495 19 2010 6560 1019 32 1210 315 14 5407 1053 23 13 177 2387 69 11 159 1834 50 2018 553 19 2011 6358 1069 32 1214 309 14 5333 1090 23 12 905 2468 69 10 849 1913 50 2056 555 19 2012 6131 1101 31 1214 313 14 5203 1171 23 12 548 2585 68 10 492 2026 49 2056 559 19 2013 5995 1143 31 1214 341 14 5258 1101 23 12 467 2585 68 10 411 1998 49 2056 587 19 2014 6111 1135 31 1064 331 13 5211 1096 24 12 386 2562 68 10 480 1983 50 1906 579 18 2015 6092 1137 31 1075 341 13 5216 1121 24 12 383 2599 68 10 473 2003 50 1910 596 18 Notes: Data in both the international and Irish classifications sum to the total column. IP, inpatient beds; D, day beds. aIP and D bed numbers refer to bed capacity (1980–92) and bed availability (1993–2015). bIP and D bed numbers refer to bed capacity (1980–2015). cIP and D bed numbers refer to bed capacity (1980–92) and a combination of bed capacity and availability (1993–2015) (the combination results from the aggregation of public voluntary beds (measured in bed availability) in the Irish classification and private not-for-profit beds (measured in bed capacity) among private hospitals in the Irish classification). dIP and D bed numbers refer to bed capacity (1980–92) and a combination of bed capacity and availability (1993–2015). eIP and D bed numbers refer to bed capacity (1980–92) and bed availability (1993–2015). fIP and D bed numbers refer to bed capacity (1980–2015). Data sources 1. Privately funded hospitals (private for-profit, some private not-for-profit, private (Irish classification)): Table S1 2. Publicly funded hospitals (public, some private not-for-profit, public (Irish classification)): Department of Health’s annual statistics series.15,19 However, this article excludes district hospitals for all years (the Department of Health included district hospitals in its data for 1980–91). Also, because the Health in Ireland: Key Trends series20 does not provide a breakdown of bed numbers by hospital, the Department of Health supplied these data to the author for 2011–15. To distinguish public voluntary and non-voluntary hospitals, for 1980–2003 data, voluntary and HSE/Health Boards hospitals are distinguished in Department of Health statistics and this classification was followed; but for 2004–15, hospitals are not distinguished in such a way in the published data, therefore, the annual Activity in Acute Public Hospitals in Ireland series13 was used (its Appendix I lists and classifies hospitals into voluntary and non-voluntary). Also, this article excludes Monaghan General Hospital’s 23 D beds in 2010–15 because it had no IP beds left, whereas Department of Health Statistics still counted its 23 D beds for those years. Fig. 1 View largeDownload slide Trends in hospital beds, 1980–2015. (A) Change in inpatient bed numbers since 1980 by type of hospital (international hospital classification). (B) As for A, but using the Irish hospital classification. (C) Day care beds as percentage of hospital beds, by type of hospital (international hospital classification). (D) As for C, but using the Irish hospital classification. Note: See Table 1 notes for caveats about data comparability over time and across series. Fig. 1 View largeDownload slide Trends in hospital beds, 1980–2015. (A) Change in inpatient bed numbers since 1980 by type of hospital (international hospital classification). (B) As for A, but using the Irish hospital classification. (C) Day care beds as percentage of hospital beds, by type of hospital (international hospital classification). (D) As for C, but using the Irish hospital classification. Note: See Table 1 notes for caveats about data comparability over time and across series. Between 1980 and 2015, the number of PFP inpatient beds rose from 0 to 1075. The first three PFP hospitals opened in the mid-1980s, followed by a large expansion in the 2000s, reaching a total of 13 in 2015. Between 1980 and 2015, the number of public beds decreased from 7028 to 6092. Many beds were closed in the late 1980s and since 2008 due to austerity measures. But the most significant decrease took place in the PNFP sector, whose inpatient bed numbers were nearly halved between 1980 and 2015, from 9601 to 5216. Many of these hospitals were funded by the government and closed due to spending cuts. Moreover, many were owned and managed by religious orders, which either lacked the financial resources to operate modern facilities, or whose members became too old to maintain services. Over the time period surveyed, PFP hospitals took over eight unsustainable PNFP hospitals. Similarly, in terms of the Irish hospital classification, between 1980 and 2015, inpatient beds dropped from 15 111 to 10 473 in public hospitals but increased from 1518 to 1910 in private hospitals (Differences between the numbers presented here and those in other reports are sometimes due to other reports including non-acute hospitals (e.g., p. 227 in Ref.22)). It is interesting to examine how the shift in the bed mix between inpatient and day beds has varied by hospital type (Fig. 1C and D). All hospitals began to use day beds in the 1980s, gradually increasing their numbers throughout the 1990s, and particularly in the 2000s. The main reasons for this development are technological advances permitting more rapid treatment for a range of procedures and public funding cuts that have restricted inpatient beds growth.23 PFP hospitals embraced day beds to the greatest extent, followed by PNFP and public hospitals. The more commercial hospitals thus restructured their bed mix more in favor of day beds: by 2015, 24.1% of PFP hospital beds were day beds, compared to 17.7% for PNFP and 15.7% for public hospitals. This is explained by the fact that public hospitals treat long-term illnesses to a greater extent than PFP ones, which focus on profitable, quicker procedures. Interviews with hospital managers and medical staff also pointed to the role of private health insurance companies in pressurizing hospitals to move towards day beds to save money. PFP hospitals are more subject to such pressures than public hospitals, with PNFP hospitals in between. Similarly, in terms of the Irish hospital classification, by 2015, 23.8% of private hospital beds were day beds, compared to 16.1% in public hospitals. Ireland’s privatization in international context Table 2 situates Ireland’s privatization experience in an international context. On one hand, privatization in Ireland has been real but less intense than in some other countries, with PFP hospitals accounting for 8.6% of inpatient beds in 2014. This is lower than countries like Germany (30.0%), France (23.7%) and Greece (32.8%), but higher than nations like Denmark (2.2%) and Finland (3.8%). Ireland was a relative latecomer to privatization, whose scale was still low in the 1990s, but grew relatively rapidly thereafter. Table 2 Percentage of total national inpatient beds by hospital type per country according to OECD statistics. 1995 2000 2005 2010 2014 Australia  Public 72.4 68.2 69.4 69.5  PNFP 13.4 14.2 14.2 14.3  PFP 14.2 17.6 16.4 16.2 Austria  Public 75.6 74.7 73.3 70.9 69.2  PNFP 17.4 18.2 17.7 18.0 17.4  PFP 7.0 7.2 9.0 11.1 13.5 Denmark  Public 99.2 95.9 95.5 93.8  PNFP 2.7 2.4 4.0  PFP 0.8 1.4 2.1 2.2 Finland  Public 96.7 96.7 96.3 95.6 96.2  PNFP 0.0 0.0 0.0 0.0 0.0  PFP 3.3 3.3 3.7 4.4 3.8 France  Public 65.6 65.4 62.5 62.4  PNFP 14.6 14.1 14.0 13.9  PFP 19.8 20.5 23.4 23.7 Germany  Public 43.4 40.6 40.7  PNFP 30.4 29.8 29.3  PFP 26.2 29.7 30.0 Greece  Public 69.4 69.6 68.8 65.3  PNFP 1.2 3.0 2.7 1.9  PFP 29.4 27.4 28.4 32.8 Irelanda  Public 47.6 51.8 52.9 49.8 49.3  PNFP 51.1 45.7 43.0 41.0 42.1  PFP 1.3 2.5 4.1 9.2 8.6 Portugal  Public 78.5 77.8 75.4 73.1 70.1  PNFP 17.3 17.1 18.7 18.3 19.7  PFP 4.2 5.1 6.0 8.6 10.2 Spain  Public 67.5 66.7 65.7 68.7 68.6  PNFP 13.0 15.4 14.6 13.1 12.5  PFP 19.5 18.0 19.7 18.2 18.9 United States  Public 30.1 26.3 25.5 24.5  PNFP 57.6 60.6 60.7 60.4  PFP 12.3 13.1 13.8 15.1 1995 2000 2005 2010 2014 Australia  Public 72.4 68.2 69.4 69.5  PNFP 13.4 14.2 14.2 14.3  PFP 14.2 17.6 16.4 16.2 Austria  Public 75.6 74.7 73.3 70.9 69.2  PNFP 17.4 18.2 17.7 18.0 17.4  PFP 7.0 7.2 9.0 11.1 13.5 Denmark  Public 99.2 95.9 95.5 93.8  PNFP 2.7 2.4 4.0  PFP 0.8 1.4 2.1 2.2 Finland  Public 96.7 96.7 96.3 95.6 96.2  PNFP 0.0 0.0 0.0 0.0 0.0  PFP 3.3 3.3 3.7 4.4 3.8 France  Public 65.6 65.4 62.5 62.4  PNFP 14.6 14.1 14.0 13.9  PFP 19.8 20.5 23.4 23.7 Germany  Public 43.4 40.6 40.7  PNFP 30.4 29.8 29.3  PFP 26.2 29.7 30.0 Greece  Public 69.4 69.6 68.8 65.3  PNFP 1.2 3.0 2.7 1.9  PFP 29.4 27.4 28.4 32.8 Irelanda  Public 47.6 51.8 52.9 49.8 49.3  PNFP 51.1 45.7 43.0 41.0 42.1  PFP 1.3 2.5 4.1 9.2 8.6 Portugal  Public 78.5 77.8 75.4 73.1 70.1  PNFP 17.3 17.1 18.7 18.3 19.7  PFP 4.2 5.1 6.0 8.6 10.2 Spain  Public 67.5 66.7 65.7 68.7 68.6  PNFP 13.0 15.4 14.6 13.1 12.5  PFP 19.5 18.0 19.7 18.2 18.9 United States  Public 30.1 26.3 25.5 24.5  PNFP 57.6 60.6 60.7 60.4  PFP 12.3 13.1 13.8 15.1 aFor Ireland, data refer to acute hospitals only, which account for ~90% of total hospital beds; data refer to a mix of bed capacity and availability (for details see table 1 notes). In general, OECD data for other countries refer to bed availability for all hospital types, although there are exceptions and a number of breaks in countries’ statistical series due to shifts in counting bed capacity or availability over time (e.g. Canada), inclusion or exclusion of certain hospitals, etc. For details, see Ref.25 View Large Table 2 Percentage of total national inpatient beds by hospital type per country according to OECD statistics. 1995 2000 2005 2010 2014 Australia  Public 72.4 68.2 69.4 69.5  PNFP 13.4 14.2 14.2 14.3  PFP 14.2 17.6 16.4 16.2 Austria  Public 75.6 74.7 73.3 70.9 69.2  PNFP 17.4 18.2 17.7 18.0 17.4  PFP 7.0 7.2 9.0 11.1 13.5 Denmark  Public 99.2 95.9 95.5 93.8  PNFP 2.7 2.4 4.0  PFP 0.8 1.4 2.1 2.2 Finland  Public 96.7 96.7 96.3 95.6 96.2  PNFP 0.0 0.0 0.0 0.0 0.0  PFP 3.3 3.3 3.7 4.4 3.8 France  Public 65.6 65.4 62.5 62.4  PNFP 14.6 14.1 14.0 13.9  PFP 19.8 20.5 23.4 23.7 Germany  Public 43.4 40.6 40.7  PNFP 30.4 29.8 29.3  PFP 26.2 29.7 30.0 Greece  Public 69.4 69.6 68.8 65.3  PNFP 1.2 3.0 2.7 1.9  PFP 29.4 27.4 28.4 32.8 Irelanda  Public 47.6 51.8 52.9 49.8 49.3  PNFP 51.1 45.7 43.0 41.0 42.1  PFP 1.3 2.5 4.1 9.2 8.6 Portugal  Public 78.5 77.8 75.4 73.1 70.1  PNFP 17.3 17.1 18.7 18.3 19.7  PFP 4.2 5.1 6.0 8.6 10.2 Spain  Public 67.5 66.7 65.7 68.7 68.6  PNFP 13.0 15.4 14.6 13.1 12.5  PFP 19.5 18.0 19.7 18.2 18.9 United States  Public 30.1 26.3 25.5 24.5  PNFP 57.6 60.6 60.7 60.4  PFP 12.3 13.1 13.8 15.1 1995 2000 2005 2010 2014 Australia  Public 72.4 68.2 69.4 69.5  PNFP 13.4 14.2 14.2 14.3  PFP 14.2 17.6 16.4 16.2 Austria  Public 75.6 74.7 73.3 70.9 69.2  PNFP 17.4 18.2 17.7 18.0 17.4  PFP 7.0 7.2 9.0 11.1 13.5 Denmark  Public 99.2 95.9 95.5 93.8  PNFP 2.7 2.4 4.0  PFP 0.8 1.4 2.1 2.2 Finland  Public 96.7 96.7 96.3 95.6 96.2  PNFP 0.0 0.0 0.0 0.0 0.0  PFP 3.3 3.3 3.7 4.4 3.8 France  Public 65.6 65.4 62.5 62.4  PNFP 14.6 14.1 14.0 13.9  PFP 19.8 20.5 23.4 23.7 Germany  Public 43.4 40.6 40.7  PNFP 30.4 29.8 29.3  PFP 26.2 29.7 30.0 Greece  Public 69.4 69.6 68.8 65.3  PNFP 1.2 3.0 2.7 1.9  PFP 29.4 27.4 28.4 32.8 Irelanda  Public 47.6 51.8 52.9 49.8 49.3  PNFP 51.1 45.7 43.0 41.0 42.1  PFP 1.3 2.5 4.1 9.2 8.6 Portugal  Public 78.5 77.8 75.4 73.1 70.1  PNFP 17.3 17.1 18.7 18.3 19.7  PFP 4.2 5.1 6.0 8.6 10.2 Spain  Public 67.5 66.7 65.7 68.7 68.6  PNFP 13.0 15.4 14.6 13.1 12.5  PFP 19.5 18.0 19.7 18.2 18.9 United States  Public 30.1 26.3 25.5 24.5  PNFP 57.6 60.6 60.7 60.4  PFP 12.3 13.1 13.8 15.1 aFor Ireland, data refer to acute hospitals only, which account for ~90% of total hospital beds; data refer to a mix of bed capacity and availability (for details see table 1 notes). In general, OECD data for other countries refer to bed availability for all hospital types, although there are exceptions and a number of breaks in countries’ statistical series due to shifts in counting bed capacity or availability over time (e.g. Canada), inclusion or exclusion of certain hospitals, etc. For details, see Ref.25 View Large On the other hand, Ireland’s hospital sector can still be described as highly private because PFP and PNFP hospitals account for half (50.7%) the national bed stock, with public hospitals accounting for 49.3%. But even countries with a more developed PFP sector have kept a higher proportion of their beds under public ownership, such as France (62.4%) Spain (68.6%) and Austria (69.2%). The difference is explained by Ireland’s relatively large number of beds in PNFP hospitals, established by the Catholic Church, Protestant churches and charities.24 Discussion Main findings of this study This study presents an examination of trends in bed supply over time in Ireland, focusing on privatization within the context of government policy on bed provision. Figure 1 and Table 1 suggest the following trends from 1980 to 2015. Overall, the number of inpatient beds decreased significantly. The number of PFP beds rose from 0 to 1075, inpatient beds were nearly halved in PNFP hospitals, from 9601 to 5216, and decreased from 7028 to 6092 in public hospitals. Also, by 2015, 24.1% of PFP hospital beds were day beds, compared to 17.7% for PNFP and 15.7% for public hospitals. In the Irish classification, between 1980 and 2015, inpatient beds dropped from 15 111 to 10 473 in public hospitals but increased from 1518 to 1910 in private hospitals; by 2015, 23.8% of private hospital beds were day beds, compared to 16.1% in public hospitals. What is already known on this topic It is known that the number of private acute hospitals has grown in Ireland over the last several decades and that similar privatization trends have characterized many other countries. It is also known that technological advances and cost pressures have led hospitals to utilize more day beds. What this study adds This study presents the annual number of private hospital beds in Ireland since 1980 for the first time, together with international comparisons. The differences in the evolution of day and inpatient beds by hospital type have been described. Also, this study presents a reclassification of Irish acute hospitals according to international norms, facilitating comparative international research. Limitations of the study This study’s private hospital data were collected via direct requests to hospitals and complemented by other sources such as the Irish Medical Directory. Ideally, these data should have been collected by the Irish government through an appropriate systematic data collection process. Unfortunately, this is not done for private hospitals. Retrospective direct data requests to hospitals involve potential data quality losses, as discussed above. Conclusion Privatization has transformed health care systems worldwide. Since the 1980s, the Irish government has supported for-profit hospital care. Thus, PFP hospitals have grown over the last three decades. Conversely, the public hospital system has been neglected. In particular, during two periods of austerity in the 1980s and in the years after the 2008 financial crisis, a number public and PNFP beds were eliminated. Public hospitals have thus had difficulty meeting the demand for care and long waiting lists have become an acute national problem. Supplementary data Supplementary data are available at the Journal of Public Health online. Acknowledgements The author would like to thank two anonymous reviewers who provided very insightful and constructive comments that have strengthened the article considerably. Many thanks are also due to former and current officials in private hospitals and health insurance companies as well as analysts in the Department of Health and Health Service Executive who have supplied data to the author. References 1 Wren M-A . Unhealthy State: Anatomy of a Sick Society . Dublin : New Island , 2003 . 2 Turner B . Unwinding the State subsidisation of private health insurance in Ireland . Health Policy 2015 ; 119 : 1349 – 57 . Google Scholar CrossRef Search ADS PubMed 3 Connolly S , Wren M-A . The 2011 proposal for Universal Health Insurance in Ireland: potential implications for healthcare expenditure . Health Policy 2016 ; 120 : 790 – 6 . Google Scholar CrossRef Search ADS PubMed 4 OECD . Health Statistics. Paris: OECD, 2017. http://stats.oecd.org/ (4 August 2017, date last accessed). 5 Department of Health . Health in Ireland, Key Trends 2015. Dublin: Department of Health, 2015. 6 Thomas S , Burke S , Barry S . The Irish health-care system and austerity: sharing the pain . Lancet 2014 ; 383 : 1545 – 6 . Google Scholar CrossRef Search ADS PubMed 7 Burger J. Jimmy Sheehan’s mission to heal. Legatus. 2013 http://legatus.org/jimmy-sheehans-mission-to-heal/ (12 January 2018, date last accessed). 8 Tussing AD , Wren M-A . How Ireland Cares: The Case for Health Care Reform . Dublin : New Island , 2006 . 9 André C , Hermann C . Privatisation and marketisation of health care systems in Europe. In: Frangakis M , Hermann C , Huffschmid J , Lorant K (eds) . Privatisation Against the European Social Model . London : Palgrave Macmillan , 2009 : 129 – 44 . Google Scholar CrossRef Search ADS 10 Department of Health . Health Statistics . Dublin : Department of Health , various years. 11 Eurostat . Definitions and data collection specifications on health care statistics (non-expenditure data). 10 July 2016. https://circabc.europa.eu/d/a/workspace/SpacesStore/3a37b5c6-2b85-4bc2-a254-06e0976355a5/ESTAT-OECD-definitions-CARE-non-expenditure%20(09.07.2010).pdf (12 January 2018, date last accessed). 12 Nolte E , Pitchforth E , Miani C et al. . The changing hospital landscape: an exploration of international experiences . Rand Health Q 2014 ; 4 : 1 . 13 Healthcare Pricing Office . Activity in Acute Public Hospitals in Ireland Annual Report . Dublin : Health Service Executive various years . 14 OECD, Eurostat, WHO . A System of Health Accounts. Paris: OECD. 15 Department of Health . Health Statistics 1993 Prepared by Information Management Unit, Department of Health . Dublin : Department of Health , 1993 . 16 Guéret M . Irish Medical Directory: The Directory of Irish Healthcare . Dublin : Irish Medical Directory , various years. 17 Vision-net. https://www.vision-net.ie/ (12 January 2018, date last accessed). 18 Department of Health . Personal Communication (Email). Email from Department of Health Official to Julien Mercille. 2017 . 19 Department of Health . Health in Ireland, Key Trends 2017 . Dublin : Department of Health , 2017 . 20 Health Service Executive . National Service Plan 2006 . Dublin : Health Service Executive , 2005 . 21 Central Statistics Office . Population. Dublin: Central Statistics Office, 2017 . http://www.cso.ie/en/statistics/population/ (12 January 2018, date last accessed). 22 Brick A , Nolan A , O’Reilly J et al. . Resource Allocation, Financing and Sustainability in Health Care . Dublin : Economic and Social Research Institute , July 2010 . 23 Eurostat . Hospital Discharges and Length of Stay Statistics. 2016. http://ec.europa.eu/eurostat/statistics-explained/index.php/Hospital_discharges_and_length_of_stay_statistics (12 January 2018, date last accessed). 24 Barrington R . Health, Medicine and Politics in Ireland 1900–1970 . Dublin : Institute of Public Administration , 1987 . 25 OECD . OECD Health Statistics 2017: Definitions, Sources and Methods: Hospital Beds . Paris : OECD , 2017 . © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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Journal of Public HealthOxford University Press

Published: Feb 16, 2018

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