Hospital reform
Nigel Edwards
The same problems across Europe
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Growing demand
Patients increasingly have.....
Multiple chronic conditions
Poly-pharmacy
Dementia
A need for care and support at home
Ageing populations
16
15
14
13
12
11
10
9
8
1970
1975
1980
1985
1990
1995
2000
% of population aged 65+ years in Europe
2005
and......
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Contracting finances & tax revenues
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The task is going to be how to do more
with less
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This means some very different
thinking
International trends
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Focus on process efficiency
Regionalisation of specialist work
Fewer hospitals
Reduced beds
Pressures to centralise
 Links
between quality and volume
 Other economies of scope & scale
 Perceived market advantages
 Workforce
 Shortages
 Working
time restrictions
Pressures to decentralise
 Migration
of care out of hospitals
 Payer
policy
 Out of hospital care assumed to be cheaper
 Preferred by users
 Technology
 Sustainability
& environmental concerns
Restructuring hospitals
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Throughout Europe, the number of
hospital beds has been reduced in
recent years and they are now used
more intensively
Increase in day surgery
700
600
500
400
Acute care hospital beds per
100,000 population in the EU
300
200
100
0
1980
1985
1990
1995
2000
2005
Source: WHO Europe, health for all database, January 2011
Average length of stay, acute care hospitals only,
European Union average
12
10
8
6
4
2
0
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
Acute (short-stay) hospitals per 100,000
Netherlands
Israel
United Kingdom
Hungary
Slovenia
Ireland
Croatia
Spain
Portugal
Slovakia
Belgium
Czech Republic
Austria
Greece
Italy
Poland
Germany
Switzerland
Lithuania
Estonia
Latvia
France
0
0.5
1
1.5
2
2.5
3
3.5
Acute beds per 100,000
Acute care hospital beds per 100000, Last available
Germany 2008
Austria 2008
Lithuania 2008
Slovakia 2008
CARK 2009
Romania 2008
Poland 2008
Luxembourg 2008
Latvia 2009
Belgium 2009
Greece 2008
Estonia 2008
Slovenia 2008
EU 2008
Iceland 1996
France 2008
Croatia 2008
Switzerland 2008
Italy 2008
Denmark 2008
Netherlands 2008
Portugal 2008
Malta 2009
United Kingdom 2008
Ireland 2007
Norway 2008
Spain 2008
Turkey 2008
Serbia 2009
Sweden 2005
Israel 2009
Finland 2008
0
500
1000
In-patient care admissions per 100, Last available
Austria 2008
Romania 2009
Finland 2009
Germany 2008
Luxembourg 2007
Lithuania 2009
Hungary 2008
Czech Republic 2009
France 2009
Greece 2006
Poland 2008
Latvia 2009
Slovakia 2009
Norway 2009
Estonia 2009
Slovenia 2009
Israel 2009
EU 2009
Croatia 2009
Switzerland 2008
Belgium 2007
Sweden 2007
Ireland 2008
Denmark 2009
Italy 2008
United Kingdom 2009
Portugal 2008
Spain 2008
Netherlands 2008
0
10
20
30
International trends
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Quality
Safety
Healthcare infections and antibiotic
resistance
International trends
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Changes in governance
Thinking about the hospital in new
ways
Changing governance and
management
Context
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Frequent reforms
Groups of GPs will take over purchasing
function
More use of patient choice, competition &
market mechanisms
DRG & tariff payment
The state to become less responsible for
day to day management of healthcare
Hospital governance
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Make hospital management more
professional
Reduce political interference
Introduce business discipline
Become more like other parts of the
economy
Hospital governance
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Link clinical decisions to financial decisions
Strong involvement of doctors in
management
Reflects a general trend to decentralised
decisions and a reduced role for central
government
English reform
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Create independent Foundation Hospitals
Governed by a Board
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Appointed by governors elected by members:
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5 Non executive Directors and a Chairman
5 Executives
Staff
Patients
Public
Note: No ministry or government representative
Freedoms
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Surpluses retained
Strategy
Investment
Pay and conditions
Management arrangements
Verdict
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Less change in performance than was hoped
Less use of freedoms than expected
Dealing with failure is still a problem
Change of this type takes time
Governments try and find new ways to impose
control
Now some interest in Concesión Administrativa
Challenging the idea of
hospitals
Is the concept still valid?
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Hospitals are collections of different
functions
There were good reasons for putting
these together but do these still apply?
Rethinking hospitals 1
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Many hospitals are a collection of things that
no longer fit together
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Too specialised for much of their current general
work
Not specialist enough for the specialist work
Not sufficiently integrated with other services –
primary & social care
The model only seems to work when its
growing
Different types of activity
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Relatively predictable, self-contained standardised,
protocol driven ‘factory’ model
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Complex, uncertain, messy and with multiple
external relationships:
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Elective surgery
Imaging
Laboratories
Emergency medicine
Primary care activity
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In the emergency department and outpatients
Rethinking hospitals 2
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Should there be more separation of
different types of process, patient
condition etc?
Rather than separation based on the
specialism of the doctors?
This might mean......
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‘Focussed factories’ for high throughput
elective surgery
Multidisciplinary teams for messy & complex
problems
Hospitals need to be much more integrated
with primary care in the management of
chronic disease
Close links to social care to allow rapid
discharge & admission avoidance
This might mean.....
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Hospitals not used for:
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Rehabilitation
End of Life
Other treatments possible at home
Hospital for a chronic condition should be
seen as indicating a failure of the system
Rethinking hospitals 2
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Change the physical structure of the
hospital
Fundamental changes in its
relationship with patients, primary care
and care outside hospitals
Change the way its staff work
This requires
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New incentives for hospitals
New skills for primary care
Redesigning the work of specialists in
chronic diseases
New mindsets
Changing the rules
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Systems produce the results they are designed to
get – so change the design rules to change the
results
Old Rules
New Rules
Redesign patient experience
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Treat each episode as a single (surprising)
event
Anticipate need and manage years of care
Integrated approach with primary care
We treat patients
Patient self care
Remote and home care
Treat patients as though their time is free
Eliminate wasted time and travel
Redesign patient experience
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Move patients
Move staff and information
Batch and queue
Patients flow through the system
Patients (cont.)
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Give your details & history many times
Provide information once
Patients come to the ‘wrong place’
Systems are designed to be able to route the
patient or provide the appropriate responses
Front line
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Improve leadership & middle
management
Front of house
Focus on operations and improvement
Create space to think
Train staff to solve root causes of
problems
Redesign how staff work
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Silos based on clinical disciplines
Teams and functions based on patient need
and processes
Escalate up from junior to senior
See someone senior and delegate
See a doctor
See the most appropriate professional
Reduce the skills on wards
Make sure the right skills are present
…..how staff work
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9-5 working
Longer days
Most things stop at the weekend
Senior staff and diagnostics available
Specialists manage patients
Specialists provide advice to generalists
Specialists work in the one hospital
Specialists work in networks
Rethink the system
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Beds are a symbol of prestige and a way of
generating income
Beds are a cost and a liability
Care is fragmented between providers
Integrated care
Chaos and improvisation
Systematic and organised
Pathway based
Variation tracked and feedback to staff
Conclusions
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Some very challenging times a head
Better integration and co-ordination will
be vital
Getting much more professional in
how systems are run will be very
important