Hospital reform

Inverting the health pyramid will… put the system back on its feet
On the one hand, you have a maternity ward that receives two births a week, and on the other hand, you have to wait too long for your surgery because the hospital lacks surgeons. Meanwhile, the neurologist and cardiologist waste their valuable time writing prescriptions. Whether we want it or not, the Polish health system needs reform. And urgently so.

The inverted health pyramid has been mentioned many times in recent months – not only in ministerial offices and hospital emergency rooms, or specialist publications. It’s great that discussions about healthcare reform are becoming commonplace now and becoming a talking point for a Sunday lunch. Everybody can have their say, including Uncle Jerry and Grandma Sophie. In many cases, however, such home debates take the form of discussions about the selection of the national football team coach. Everyone knows best 😉 But do we know what we’re even talking about? Do we realise what is at stake in this game?

Dramatic headlines in the media heighten the atmosphere: “Maternity wards with fewer than 300 births speculated to become excluded from the network” and “1/3 of surgery wards to be closed.” Journalists are heating up the atmosphere, while in the administrative districts, a pale political fear is raining down on local government officials. Close a hospital? “Not on my watch!”

There’s no willingness to make the unpopular decision, but there’s also no willingness to explain to the patient (also, after all, a voter) why they’re being operated on by a 78-year-old. No one explains to such a patient why a retired surgeon is the only available one, doing a courtesy to the director, who’s unable to attract new staff to the small hospital they manage. Here, the development opportunities are negligible… Also, nobody dares to upset expectant families. After all, they won’t like having to travel a little further to the delivery room with the labour. So, no one speaks too loudly about the fact that there is no anaesthetist support in hospitals that receive two births a week, and, if there are complications, no neonatology unit either. No matter what, the hospital has to be closed! Are you sure?

Accessibility has its limits… hospitals aren’t convenience stores where proximity matters.
There are 690 public hospitals in Australia, and only less than half of them have 24-hour wards and an ED. The area of Australia is almost 80% of that of Europe, and in Poland, we have over 900 hospitals¹. In Norway, fewer than 95 hospitals serve the people in the far north, of which only half are open 24 hours a day. I’m not mentioning the now famous 40 Danish hospitals, only half of which have an ED. In the Health Care Index by Country 2023 (Numbeo), Poland is ranked 46th, Australia 15th, Norway 8th, and Denmark 21st².

As you can see, without one of the highest numbers of hospital beds per 100,000 inhabitants³ in Europe, you can also live a long and healthy life and not worry about dying because of not receiving care… Of course, each such bed (whether used sensibly or not) costs money. Expenditure on hospital treatment accounts for over 50% of the NHF budget in Poland and, due to obligatory annual increases in medical staff pay, the dynamics of its growth in the plans for 2025^4,5 is higher than all other types of services!

We aren’t learning the lessons of previous reforms
And yet, some of the biggest sceptics associate inverting the health pyramid with turning everything upside down. Or perhaps the truth is that we’re now upside down and it’s worth doing something to stand on our feet, others ask. The last six years have seen health care expenditure double⁶. “Why close hospitals then?” more informed patients ask.

In discussions about health care reform⁷, there are infrequent arguments about the opportunities that will be gained from sound streamlining of the costs of operating the hospital system. We currently have the 5th highest rate of hospital costs as a share of the amounts budgeted for health. The funds freed up can be used to strengthen the competencies of doctors who are closer to patients, thus shortening the diagnostic pathway, and much cheaper long-term care, which is virtually non-existent. Poland ranks 3rd from the bottom in terms of the number of beds in long-term care units per 100,000 inhabitants. We spend less on health per capita than half the EU average^8,9, with the smallest amount on prophylaxis¹⁰ – the EU average is 6%, while in our country only 2% of health expenditure is spent on disease prevention¹¹.

However, we can afford to increase the financial resources for hospital treatment. It should be added that the treatment mentioned also still includes admitting patients for examinations that can easily be performed at primary care and specialist outpatient care units. Broadening the catalogue of services and increasing the valuation of outpatient procedures would not only reduce the operating costs of outpatient clinics but would also reduce many months’ waiting times for hospital admission for less sophisticated therapies. The rates of avoidable hospital admissions are among the highest in Europe. In Poland, hospitalisation rates for conditions that could be effectively treated in outpatient settings are among the highest in the EU^12,13 (Fig. 13). These high rates are indicative of gaps in the provision of primary care and specialist outpatient care.

We also have one of the lowest rates of doctors per 100,000 inhabitants in Europe and one of the highest average numbers of visits per capita. Of the 20 minutes of the visit, according to statistics, the patient interview takes four minutes. How, then, does one of the most important diagnostic tools – a proper interview – come into play here?

Time for kaizen
It’s time to make many small changes that have the potential to spark a systemic revolution! Let’s involve non-medical staff in the treatment process. I’m aware that we aren’t systemically ready for technicians to perform ultrasound examinations, which is a reality in the UK, but the implementation of a triage procedure following the example of some Scandinavian countries, which can be performed at specialist outpatient care units by nurses, seems doable here.

What I mean is also the VBHC (Value Based Healthcare – treatment based on outcomes) approach in more services. Additionally priced mandatory follow-ups in chronic diseases. Screening with tangible incentives not only for practitioners but also (and perhaps primarily) for patients. After all, it’s their health that’s at stake!

The financial and staff resources freed up will ensure the availability of better-priced services. Elements of VBHC and patient incentives will make it in the interest of providers to provide services, rather than failing to provide them, as is the case today (capitation rates, flat rates). In turn, it will be in the interest of patients to turn up for examinations.

Another issue is the implementation of rapid pathways for further diagnosis and possible therapies for patients who require it after screening as part of coordinated care. We already have a good basis and extensive experience related to the operation of DILO (oncological diagnosis and treatment) cards, among other initiatives.

Finally, the implementation of new technologies that provide tangible support for patients. There are already positive effects and proven effectiveness – for instance, in the area of diabetes monitoring. More treatment monitoring solutions for chronic diseases are in the pipeline.

Why do we not respect the resources we have?
As you can see, we have a basis for improving the system, but we aren’t talking about how to support medical staff effectively. The introduction of electronic medical records awaits, and more forms, consents, and more complicated reimbursement requirements are coming.

Can our system afford to have specialists writing prescriptions, referrals, recommendations, checking the conditions of reimbursement for a drug, etc.¹⁴on their own? Maybe assistant staff, care coordinators, or medical secretaries need to be involved for optimisation purposes.

Optimising patient visits and staff work, and changing the working model is a prerequisite here! It is an operational tool – no less important than product tools (services and therapies), and procedural tools (patient pathways and algorithms for cooperation between medical entities with different scopes and specialisations).

Developing such a set of tools and implementing them will mean a proper reform, and the optimisation of hospitals and the closure of some wards to establish in their place “slimmed-down” outpatient diagnostic and treatment centres, will be the cost of it.

Not the only one, though. The second, an equally important and urgent one, is patient education, but that is a topic for another article. However, if patients experience positive change, if only in a narrow area that is properly communicated and properly accounted for, the reforms will find supporters, and perhaps we will have pickets and protests about not closing hospitals whose operation isn’t viable. Let’s start with the first steps to get out of the vicious circle we’re now stuck in.

There will be another article soon about how patients should be educated.

Footnotes:

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