Hospital reformNigel Edwards

The same problems across Europe

Growing demand Patients increasingly have..... Multiple chronic conditions Poly-pharmacy Dementia A need for care and support at home

Ageing populations

8

9

10

11

12

13

14

15

16

1970 1975 1980 1985 1990 1995 2000 2005

% of population aged 65+ years in Europe

and......

Contracting finances & tax revenues

The task is going to be how to do more with less

This means some very different thinking

International trends

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

ShortagesWorking time restrictions

Pressures to decentralise

Migration of care out of hospitalsPayer policyOut of hospital care assumed to be cheaperPreferred by usersTechnology

Sustainability & environmental concerns

Restructuring hospitals

Throughout Europe, the number of hospital beds has been reduced in recent years and they are now used more intensively

Increase in day surgery

Source: WHO Europe, health for all database, January 2011

Acute care hospital beds per 100,000 population in the EU

Average length of stay, acute care hospitals only, European Union average

Acute (short-stay) hospitals per 100,000

0 500 1000

2008Germany2008Austria2008Lithuania2008Slovakia2009CARK2008Romania2008Poland2008Luxembourg2009Latvia2009Belgium2008Greece2008Estonia2008Slovenia2008EU 1996Iceland2008France2008Croatia2008Switzerland2008Italy2008Denmark2008Netherlands2008Portugal2009Malta2008United Kingdom2007Ireland2008Norway2008Spain2008Turkey2009Serbia2005Sweden2009Israel2008Finland

Acute care hospital beds per 100000, Last available

Acute beds per 100,000

0 10 20 30

2008Austria2009Romania2009Finland2008Germany2007Luxembourg2009Lithuania2008Hungary2009Czech Republic2009France2006Greece2008Poland2009Latvia2009Slovakia2009Norway2009Estonia2009Slovenia2009Israel2009EU 2009Croatia2008Switzerland2007Belgium2007Sweden2008Ireland2009Denmark2008Italy2009United Kingdom2008Portugal2008Spain2008Netherlands

In-patient care admissions per 100, Last available

International trends

Quality Safety Healthcare infections and antibiotic

resistance

International trends

Changes in governance Thinking about the hospital in new

ways

Changing governance and management

Context

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

Make hospital management more professional

Reduce political interference Introduce business discipline Become more like other parts of the

economy

Hospital governance

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

Create independent Foundation Hospitals Governed by a Board

5 Non executive Directors and a Chairman 5 Executives

Appointed by governors elected by members: Staff Patients Public

Note: No ministry or government representative

Freedoms

Surpluses retained Strategy Investment Pay and conditions Management arrangements

Verdict

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?

Hospitals are collections of different functions

There were good reasons for putting these together but do these still apply?

Rethinking hospitals 1

Many hospitals are a collection of things that no longer fit together

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

Relatively predictable, self-contained standardised, protocol driven ‘factory’ model Elective surgery Imaging Laboratories

Complex, uncertain, messy and with multiple external relationships: Emergency medicine

Primary care activity In the emergency department and outpatients

Rethinking hospitals 2

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......

‘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.....

Hospitals not used for: 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

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

New incentives for hospitals New skills for primary care Redesigning the work of specialists in

chronic diseases New mindsets

Changing the rules

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

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

Move patients Move staff and information Batch and queue Patients flow through the system

Patients (cont.)

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

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

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

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

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

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