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Hospital reform Nigel Edwards

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.

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Hospital reform Nigel Edwards

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  1. Hospital reformNigel Edwards

  2. The same problems across Europe • Growing demand • Patients increasingly have..... • Multiple chronic conditions • Poly-pharmacy • Dementia • A need for care and support at home

  3. Ageing populations % of population aged 65+ years in Europe

  4. and...... • Contracting finances & tax revenues • The task is going to be how to do more with less • This means some very different thinking

  5. International trends • Focus on process efficiency • Regionalisation of specialist work • Fewer hospitals • Reduced beds

  6. Pressures to centralise Links between quality and volume Other economies of scope & scale Perceived market advantages Workforce Shortages Working time restrictions

  7. 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

  8. 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

  9. Acute care hospital beds per 100,000 population in the EU Source: WHO Europe, health for all database, January 2011

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

  11. Acute (short-stay) hospitals per 100,000

  12. Acute beds per 100,000

  13. International trends • Quality • Safety • Healthcare infections and antibiotic resistance

  14. International trends • Changes in governance • Thinking about the hospital in new ways

  15. Changing governance and management

  16. 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

  17. Hospital governance • Make hospital management more professional • Reduce political interference • Introduce business discipline • Become more like other parts of the economy

  18. 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

  19. 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

  20. Freedoms • Surpluses retained • Strategy • Investment • Pay and conditions • Management arrangements

  21. 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

  22. Challenging the idea of hospitals

  23. Is the concept still valid? • Hospitals are collections of different functions • There were good reasons for putting these together but do these still apply?

  24. 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

  25. 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

  26. 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?

  27. 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

  28. 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

  29. 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

  30. This requires • New incentives for hospitals • New skills for primary care • Redesigning the work of specialists in chronic diseases • New mindsets

  31. 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

  32. 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

  33. Redesign patient experience • Move patients • Move staff and information • Batch and queue • Patients flow through the system

  34. 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

  35. 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

  36. 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

  37. …..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

  38. 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

  39. 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

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