Hospitals across Europe are under pressure. They all tend to have business models which rely on growing income and payers that are increasingly trying to contain them.
Big questions are being asked about future strategy but there is surprisingly little public debate about this important part of the health system and there is insufficient policy analysis.
Firstly, the UK has a pattern of fewer, larger hospitals than the rest of Europe and along with Norway, Sweden, the USA and the Netherlands some of the lowest bed numbers per 1000 population in the OECD.
Institutions that we would consider unviable because of their small scale are common in many countries in Europe. There is a trend towards centralisation of some of these services and there has been some closure and repurposing of hospitals in most countries.
All hospitals in Europe have to come to terms with the growth in the number of patients living with multiple health problems
The UK is a particular outlier in terms of the size of obstetric units – some of the numbers of births suggested as a minimum by some of the UK participants at our European Summit were larger than the biggest units in other countries.
Secondly, the UK public sector consists of stand-alone hospitals or relatively small hospital groups in close proximity. France and Germany and to a lesser extent some other countries have large chains or groups of hospitals that have a single management and a common operating model. Hospitals not part of these groups increasingly have to think about partnering and networking with other hospitals.
All countries recognise that hospitals cannot be planned as stand-alone institutions, and in many EU countries there are regional structures that take responsibility for providing this important oversight.
Even in the Netherlands the health insurance companies are working with groups of hospitals to plan the shape of the system. England looks like an outlier both in terms of the lack of system leadership and the attempt to do strategy at the level of 52 million people.
Even in market-based systems, there is a lot of planning, and decisions about centralisation and regionalisation are accepted to be both necessary and political – there is no escape from political involvement in decisions about hospitals.
All hospitals in Europe have to come to terms with the growth in the number of patients living with multiple health problems. The growth of specialism and the way this tends to be reflected in the internal organisation of the hospital is a significant issue, especially in relation to dealing with patients with multi-morbidity.
The Royal College of Physicians commission on the future of the hospital has highlighted the need to reinvent the generalist physician to help deal with this.
This view is shared across many countries but may be less of an issue because of one glaring oddity about the UK system – the extent to which trainee doctors are still the backbone of many hospitals.
Allied to this is the need to have hospital-based specialists working more closely with primary care is recognised but cultural, regulatory and payment issues are an obstacle but there is a trend to break these down in a number of countries.
While there is a lot of rhetoric about developing transformative new models of care, in the UK the approach is usually just to make the old model of hospital provision bigger (and further away). A number of the approaches being developed in the rest of Europe challenge some of the assumptions we have about hospitals and there is more for us to learn.
Nigel Edwards is Director of the Global Healthcare Group, KPMG. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.
Edwards N (2014) ‘Under pressure: hospital organisation in Europe’. Nuffield Trust comment, 29 January 2014. https://www.nuffieldtrust.org.uk/news-item/under-pressure-hospital-organisation-in-europe