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Hospital reform Nigel 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. % of population aged 65+ years in Europe. and. - PowerPoint PPT Presentation
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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