Private hospitalisation, a neglected asset in Europe's pandemic

Dr. Paul Garassus, president of the UEHP, discusses the role of the private health system in the current COVID-19 pandemic and the regional space for improvement in this contingency.

Benoît Blanquart from interviewed Dr. Paul Garassus, neurologist, and the president of the European Union of Private Hospitals, to cover a few topics regarding the role of the private health system in the current COVID-19 pandemic and the space for improvement in the complementarity between the European private and public hospital systems in such a contingency.

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The European Union of Private Hospitals (known for its French acronym UEHP) represents twelve national federations*, including more than 5,000 private health establishments. The aim of the UEHP is to promote private hospitalization in Europe as a complementary service to the public hospital system. Its principles are to guarantee equal access to care, quality of care, and the sustainability of health systems. In Europe, 20% of the hospital supply is managed by private actors.

esanum: Dr. Garassus, has Europe shown its limits in the face of the pandemic?

Dr. Garassus: At the European level, there were plans for the event of an epidemic. States are well aware that an epidemic develops despite borders. None of these plans could be implemented because everyone was caught off guard. Expectations and cold reasoning were beaten in the face. In fact, there was no concerted European response but only attempts at national reactions to an epidemic overflow.

In the end, no government was really good, because none could be. Following this crisis, Ursula Von der Leyen [President of the European Commission] and Stélla Kyriakídes [European Commissioner for Health] logically called for assessing the health systems in Europe, for using shared tools, including organizational ones, between all actors involved.

In any case, it is difficult to think in terms of national states because this health crisis has for the most part been regional rather than national. Milan or Bergamo was devastated during the first wave, while southern Italy was relatively spared. In France, it was Alsace that suffered enormously early on, unlike Bordeaux, Montpellier, or Marseille. Governments would have had to be very adaptable to be effective, and none of them really stood out in this regard.

This regional aspect is not debated enough. Faced with a second wave, we must be able to mobilize care provision very quickly in densely populated areas that will be impacted one after the other, like a cascade, in different parts of Europe. This requires a flexible mechanism with interregional transfers of resources, such as communication channels. In the face of the pandemic, there have been some finely coordinated responses on mutual aid between states, but it is at the regional level that this is played out.

esanum: Private hospitalization can be reactive. Has it been sufficiently demanded in the current pandemic?

Dr. Garassus: Public hospitals were mobilized as a first resource because they have a stronger medical activity and a medium-term reception capacity. Above all, the public sector is always the obvious partner for health administrations since they co-regulate care provision. This "public monoculture" has once again been verified, both in France and in other European countries.

I am an "old" physician, but I was nevertheless surprised to see that in France, despite the scale of the needs, the private sector was initially somewhat neglected until the hospitals became congested. We remember the transfer to Bordeaux of Alsatian patients at a time when the clinics were empty. We can speak of a "delayed start" taking place in the use of the private hospitals’ capacities.

When we were finally called in as reinforcements we immediately welcomed the patients. 22% of the resuscitation beds dedicated to the care of COVID-19 patients in Ile-de-France depended on the private sector. We also made our premises and equipment available, and above all our staff: physicians and nurses came from clinics all over France to support colleagues in hospitals. There was no longer any label "public" or "private". The same thing happened in Italy: the private San Donato university hospital in Milan was in great demand. When San Donato itself became saturated, colleagues from the Romanian private sector even came to the rescue.

esanum: Did Europe learn from this first wave?

Dr. Garassus: Some weak points have been identified. The question of supply was very emblematic in the deficiency of European cohesion. Faced with a cruel lack of strategic equipment - masks, respirators, medicines - the states went through it alone. While Emmanuel Macron directly contacted the Chinese government, Angela Merkel gathered a hundred or so industrialists at the chancellery to ask them to find solutions to the situation. They were the ones who provided mask supplies.

Another lesson to be learned is regarding administrative barriers. We remember the Boeing loaded with masks bound for France, blocked on the Chinese airport tarmac before finally taking off for the USA. Officially the Americans paid cash and much more, but there is another explanation. The plane would have been blocked because the masks had international certification but not European. I think that lessons have been learned, in terms of procurement and resource management. And now the stocks are full.

esanum: Is the European private sector ready to face the second wave?

Dr. Garassus: Of course, we will be ready again. But the governments, who are both regulators and payers, will have to call on us and support us. In Europe, some private institutions have been sidelined. Others have been mobilized but not paid. Finally, many clinics closed due to lack of activity or have not been compensated by injunction. Although the public hospital in general is indeed the second victim of this crisis, private hospitals, in particular, are struggling to recover. There are wide disparities between countries in this respect.

France and Germany are countries that have had the intelligence to involve or keep all hospital infrastructures financially afloat, which makes them capable of coping with a second wave. Switzerland, for its part, set up an unprecedented public-private partnership during the crisis: in the Geneva canton, a mixed collegial committee decided which interventions to maintain. They were then programmed in an allocated institution according to availability. Italy has also been able to build this cooperation. In Emilia-Romagna, the public-private offer was effectively structured on three levels; the private sector, therefore, played an important role in this region, with 5,000 of the 20,000 hospital beds available. The same is true in Lombardy, where 18% of COVID-19 patients were treated by the private group San Donato.

Other states took the risk of concentrating all resources on the public sector, even when it was overwhelmed. The Portuguese government refused to pay for COVID-19 patients admitted to intensive care in the private sector. In Poland and Hungary, the governments have flatly refused to let them be cared for in the private sector. Half of Poland's private hospitals are still closed. Greece was very little affected by the first wave but all private establishments had to close down, before resuming 50% of their activity in mid-May. They did not receive any state aid. In Spain, 14% of COVID-19 patients in intensive care were treated in private establishments. Meanwhile, the clinics' income fell by 60%, and only the region of Catalonia granted them financial compensation. Those governments that choose to ignore or jeopardize private hospitalization now run the risk of scuttling care provision.

Dr. Paul Garassus