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 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  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 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

Acute beds per 100,000

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