The current structure of hospitals and the manner of work in them must change. We lack the necessary number of doctors and nurses to operate in the same way as we used to, says doctor and economist Pavel Hroboň in an interview with Zdravotnický deník. This former Deputy Minister of Health is the Programme Director of the Prague International Health Summit, a conference which this year is focusing on hospitals and their role in the 21st century. According to Hroboň, the restructuring of hospitals should begin from within, and not, for instance, from impulses coming from health insurance companies. “Change can occur only with the approval of the staff,” he believes. We discussed, for instance, how and by whom a network of hospitals should be created, whether to close down small hospitals, and where to find examples of successfully implemented changes.
How has the role of hospitals changed in modern healthcare?
The first thing that has changed are the diseases. Today’s hospitals were constructed in an era when the main problem were infectious diseases. Presently, we are primarily plagued – both in terms of health and of the economy – by chronic diseases. Society has also changed fundamentally when it comes to its preferences and time. Transportation has changed. A popular anecdote says that the network of hospitals in the Czech Republic originated so that each hospital would be accessible by a two-hour drive… by cart and bull. As usual, this is an artificially penned witticism, since of course, the origin of the network of hospitals was not something planned. When, however, we see how dense this network is, then this quip fairly clearly shows how today, it could have a completely different structure. So, the diseases are different, society is different, and the third aspect that has significantly changed is medical technology. All of these changes have an enormous impact on the functioning of a hospital.
In what sense?
If I slightly exaggerate the point, then one hundred, two hundred years ago, hospitals were the place that patients were sent to when their doctor no longer knew what to do with them. In the modern age, the acute-care hospital is a place where a patient often arrives for a clearly defined and usually quite sophisticated operation that is carried out fairly quickly. When the patient wakes up after their operation and begins to notice their surroundings, they are then usually transferred to an aftercare unit or are sent home for ambulatory care. I do not wish to suggest that all hospitals have this sort of care, but it is definitely an obvious trend. All hospitals in the Czech Republic have already felt the brunt of concentrating specialised care into a smaller number of larger hospitals under the dictate of the logics of quality assurance. The teams that carry out sophisticated operations carry them out quite often. The logics of money also dictates the work, as investments are made into expensive equipment that must be used. And the trend of the specialisation and concentration of care will continue.
But by concentrating care, we jeopardise its accessibility…
Of course, this trend of concentrated care must be balanced out by the local accessibility of care, but no one can expect to have accessible, high-quality care available on every corner. One can meet two of the three requirements of good care – price, quality, and accessibility – but by no means all three. And we all must get used to the fact that if we want to have truly top-notch care that we can also afford, it simply cannot be available on every street corner. These are all long-term trends that show why hospitals must change. A current problem on top of this is the lack of staff. I believe that these are all things that anyone who works in the healthcare sector knows deep down inside to be true.
To speak of the across-the-board closings of hospitals is complete nonsense. Plus, it is unrealistic.
The current placement of small hospitals around the country copies the former counties – they were even called County Hospitals. Are these small hospitals standing in front of the proverbial firing squad?
I would definitely not say that they are standing in front of the firing squad. To speak of the across-the-board closings of hospitals is complete nonsense. Plus, it is unrealistic. We have repeatedly experienced situations when health insurance companies suggested extensive changes upon renewing framework agreements with hospitals, dictating which wards or eventually which hospitals should be closed, and in the end, these efforts bore very little fruit. Let us therefore speak of restructuring, of what should each hospital do, and not of their closing.
Where should such thoughts about organising care originate? We have the Ministry, which deals with the entire country. We then have regions, which deal with the forms of care on the regional level. What level is the most appropriate level for planning an integrated restructuring that would lead to a meaningful whole?
There two views on the matter. One of them focuses on the size of the unit to be considered when it comes to hospital care, and the other deals with who truly has the power to do something about it. Let us, for the time being, not consider large hospitals, especially faculty hospitals. These, too, must undergo transformations, but in their case, it is not as urgent, as specialisations seem to be in their favour and they are not as understaffed by doctors as small hospitals are.
In the case of county hospitals, the answer to the question as to who is responsible for their restructuring is that it is truly the responsibility of the regional self-governments, and it is the regional level for two reasons. First, a population of approximately one million is a population that is worthwhile planning hospital care for. Secondly, regions own most of the county hospitals. The Ministry must pave the way to restructuring – if something in the current regulations is an obstacle to restructuring, then it should be removed. And insurance companies should enforce the realisation of changes, and should accommodate such transformations in their contracts, but they cannot do this instead of the hospital and its owners.
So, let us try and suggest a sort of ideal situation. How should the network of hospitals be organised on the regional level?
Allow me to divide to this question into three parts. The first is what should be changed in each hospital. We are talking about processes and organisational structures. Let me give some examples: transforming care into one-day services, introducing common ICUs, instilling a system of commonly allocated beds. Such steps require less staff, save money, and do not necessarily lead to the inaccessibility of healthcare or to a decrease in its quality, quite the contrary.
Another aspect is the issue of a hospital network. The goal is both to create one central, emergency hospital out of several originally equivalent hospitals, as well as to ensure the proper functioning of the rest, leaving the types of care that can and must stay there. However, the provision of care in the entire region must be interconnected from the perspective of the patients and of the staff. This means that both patients and staff must travel between the smaller hospitals and the central hospital providing emergency care.
The last issue is one for the long-term – what can we do to better integrate outpatient care so that it cooperates with hospitals, eventually leading to a lesser need for hospital care. Some changes can occur quite quickly, such as planning patient discharges so that their needless re-hospitalisation is minimised. We can manage this rather quickly under the current conditions. Other changes, such as better care for patients with chronic diseases, i.e. preventing their decompensation, which leads to their further hospitalisation, by timely dealing with their problems in outpatient care, such changes will take longer to introduce.
Does this mean that you agree with the recommendations to place greater emphasis on outpatient care made by such organisations as the OECD?
Yes, I agree. It is not enough to merely look at statistics and discover that we have more hospital beds, more hospitalisations, and also longer hospitalisations than other European countries do. This is all true, but it does not tell us how to change this situation. And such changes must always be made on the local level; they must correspond to local conditions.
I tip my hat to every hospital director who has been successful in convincing their doctor and nursing staff to use a system of commonly allocated beds.
I guess that such changes can be much more easily planned technically or presented expertly at a conference than actually realising them. Is it in reality a mentality issue?
Change is always primarily an issue of mentality. The fact that there is a new technology – be it medical, informational, communicative, or has to do with transportation – does not yet mean that this change will be implemented. I tip my hat to every hospital director who has been successful in convincing their doctor and nursing staff to use a system of commonly allocated beds, and luckily, we already have some of the like in the Czech Republic. For someone who has worked for thirty years in the traditional medical structure – one specialisation, one head doctor, one head nurse, and a narrow range of diagnoses – such a change is truly difficult to accept. But it is possible; if the changes are implemented with the proper amount of training, with sufficient motivation, calmly and rationally, then they are possible. It is not, however, a simple managerial task.
If people from various countries meet at your summit, how can they inspire us? And how are we able to inspire them?
We will present a whole range of examples. We have categorised them as those that have already achieved quite a lot; these serve as inspiration, namely specific examples from England, Holland, and even the United States. Then we have examples of efforts that have not yet progressed as far, but they are local and show that changes are possible even in the Czech Republic. There is a whole range of examples showing that something is beginning to change here and in Slovakia. Personally, I am looking forward to the presentation of the hospital of a new generation, built in Michalovce in Slovakia. The hospital is organised in a different manner than what we are all used to, also leading to the redistribution of rights, responsibilities, and fields of medicine between this hospital, which has assumed a central role in the region, and the neighbouring hospitals that work closely with the central one.
Whom would you like to invite to the Prague International Health Summit and why?
The management of hospitals, hospital founders and owners, health insurance companies, since they, of course, have a great interest in the restructuring of hospitals, whether it be for reasons of ensuring top-notch, accessible care for their clients, or for reasons of maintaining their own financial balance. I would like to also invite representatives of the government and the local self-governments and politicians. I would definitely and specifically invite doctors, nurses, and other clinical employees, who make up a very important group. I cannot imagine any greater changes being made in hospitals to processes or organisational structures if they are merely dictated from above. Such changes must be discussed with doctors and nurses, and in the end, it is they who must say what they need to operate in the new manner. This simply cannot be an order.
Plus, although it is a new approach, we are convinced that there are many opportunities for improving quality and effectiveness in Czech hospitals when it comes to clinical management. I dare say that the vast majority of hospitals in the Czech Republic were traditionally established so that the management could avoid being directly involved in providing healthcare. Investments were monitored, purchases were monitored, and of course, financial limits for providing healthcare services were set, and hospitals were managed in this indirect manner. Which, of course, does not mean that hospital management should tell clinical workers what they should do, but it is necessary to monitor trends in clinical care. For example, to what extent are diagnostic and treatment methods unified and standardised, to what extent recommendations of expert companies are/are not adopted, what can be done to shorten the duration of hospitalisations, etc. These are all aspects falling under clinical management. And again, those who must accept these changes and who primarily must realise these changes are the clinical workers themselves.
Usually, those hospitals that require subsidies in the long-term are those workplaces where the quality and the accessibility of care are most endangered.
Why are hospitals unmotivated to be better and to do their work differently? Is there some sort of external impulse that is missing?
Today, the lack of staff is the greatest pressure. In the past, finances also sometimes played a role. We have, however, several interesting examples of hospitals that have instigated the necessary changes on their own. Southern Bohemian hospitals have been functioning properly for a long time, although they have rather focused on unifying on the economic level and not so much on the medical level. In the past two years, many other regions have been attempting to rationalise their own system of hospitals. To rationalise means to stabilise and to adjust to the needs of the times, to ensure the accessibility and quality of care. Changes are being introduced in the Pardubice Region, very ambitious plans are being negotiated in the Zlín Region, and just recently, a new board was named in the Pilsen Region. I do not wish to offend any other subjects who are also implementing changes, but these are examples of regions who have obviously managed to organise healthcare so that it is fairly functional. On the other hand, there are regions that still must systematically subsidise healthcare using public finances, which, unfortunately, does not guarantee quality or accessibility, at all. Usually, those hospitals that require subsidies in the long-term are those workplaces where the quality and the accessibility of care are most endangered.
More pressure on introducing new forms of providing healthcare would make sense. Being informed, however, is just as important. This is precisely the reason why we are organising the Prague International Health Summit in May on theme of The Role of the Hospital in the 21st Century. We hope to show that things can be done differently. They can be done better, and it is no great alchemy.
It is not, but when the motivation is lacking…
Changes in healthcare are often viewed in a bad light, as something that must be done for the sole reason that we are understaffed or under-financed. Changes, however, are an absolutely natural part of the life of individuals and of society. And since even diseases are changing, since we, ourselves, are changing, since our society is changing, then even our hospitals must change. And the fact that we are usually addressing this too late and under the pressure of immediate problems, such as being understaffed, is, of course, a shame in its own right.
I would like to tell all hospitals in the Czech Republic to not be afraid of change! It is not at all that horrible as people tend to think. There is a wide range of good practices both from abroad and the Czech Republic. The key is to find the courage and to closely study an example of changes already made, to see what has been successfully changed for the better and what obstacles were encountered. Simply put, to apply the experience of others and to then implement these changes. What is certain is that Czech healthcare is not in a state where it must fail. It is surely not the case that there are no other ways of functioning than to import staff from abroad in order to maintain the present structure and the present manner of operating in hospitals. In fact, it is the present structure and the present way of operating that needs to change. We do not have an absolute lack of nurses and doctors. We simply do not have enough to continue operating as we did in the past. It is necessary to begin working in a new manner. This is not easy, but when you go to those hospitals that have changed the way they organise work, you see that it is possible. The worst case scenario is to merely bury your head in the sand. On the other hand, it is good to admit that there is a problem, to solve this problem, and then to achieve the greater satisfaction of both staff and patients.
Most of the changes that regions are presently introducing in hospitals stem from either the financial health of the hospital or of the staff situation, but how can we, the average Joes, recognise that they are striving for quality?
To be frank – today, as average Joes, we cannot determine this. In other words, ordinary people try to gather information by asking someone who is usually more qualified than they are, but who is sometimes less qualified. In the Czech Republic, data, even if quite basic, on the quality of healthcare are not regularly collected, analysed, or published. I consider this to be one of the main insufficiencies of Czech healthcare. We see a great difference here between the Czech Republic and countries lying to the west of us.
Why is this our case?
This is a slightly more complicated issue. So far, no long-term initiative has taken root, although many attempts have been made. I would especially mention the no longer existing National Reference Centre, which started to publish at least the most basic information about hospitals in the Czech Republic based on data collected by health insurance companies. At first, this was a project that looked quite promising, but then it fizzled out for some unknown reasons. Health insurance offices are now trying to take the first steps of renewing this project. I am deeply convinced that such a project is in the interest of patients, but also of health insurance companies and of anyone else who is interested in managing Czech healthcare in a rational manner.
Publishing data always elicited the protests of the evaluated subjects, eventually leading to their restriction and to the project’s burial.
I agree that the outcry led to restriction, but on the whole, I would evaluate the situation differently. Thanks to the fact that such data was published, quality was also improved. No other ways exist. Here is another example: today, the record-keeping of diagnoses in hospital healthcare is fairly accurate thanks to the fact that diagnoses play a role in the financing of hospitals. Health insurance companies monitor these records. On the contrary, any subject who analyses the data that insurance companies receive from the providers of ambulatory care knows that in this case, one cannot rely on diagnoses. Thus, we must name the problem, face it, place it on the table in front of us, and not until then begin to tackle it.
Can a change in legislation help?
I am deeply convinced that no changes in legislation are needed for the publishing of data on the quality of healthcare.
It is not possible to cram all of these people into the category of nurse. In reality, these are at least three types of qualification of completely different educational levels.
When it comes to the hospitals themselves, should selected laws or regulations that presently complicate their operations be changed?
There are several areas where needless regulation exists. One of them, which does not apply only to hospitals, but also to the providers of ambulatory care, is the role of non-doctor staff. Today, especially in faculty hospitals, nurses and other non-doctor staff carry out first-rate, highly professional tasks. This is an aspect that has not been addressed in the most recent discussions about changes in the curriculum for nurses. When today someone speaks of “nurses”, then they mean someone who does tasks ranging from care-taking to those requiring super specialised expertise. It is not possible to cram all of these people into the category of nurse. In reality, these are at least three types of qualification of completely different educational levels.
Furthermore, there is a whole range of regulations that are not directly rooted in the law, but only in a sub-legislative norm or are given by tradition. For instance, let us consider the issue of nocturnal emergency services. Let us stop thinking that if patients lie in hospital beds with a diagnosis of some sort, it means that such a hospital must automatically provide 24-hour emergency care in the same field as this diagnosis. This is not at all necessary, and it is an example of how to significantly simplify healthcare planning in the hospital.
Absurd situations can thus occur in smaller hospitals, where the founder must provide emergency care at all costs, paying too much to doctors on call, and no patients eventually come. They are forced to do so only because the municipal board insists upon providing emergency care for some political or prestigious reasons.
Of course, patients need to have the possibility of receiving emergency care close to home and to have the severity of their condition assessed – whether in person or by telephone. If, however, treatment, and especially emergency treatment, is required, then the only possible thing to do is to transport the patient to a hospital with the proper equipment, which is capable of ensuring quality care.
By law, health insurance companies are responsible for creating networks of healthcare facilities. Shouldn’t they be the instigators of change in hospitals?
Managing change must be an internal process. For one, changes may occur only with the approval of the staff, and secondly, each hospital knows best where they have room for improvement. The idea that the restructuring of hospitals should be headed by insurance companies is not correct. The role of insurance companies is to pressure hospitals to become more effective, to maintain the accessibility of care for their clients, and to help hospitals accommodate their own restructuring processes. Thus, I expect insurance companies to be flexible when it comes to communicating with hospitals, which should not be an effort to dictate their own ideas. Insurance companies cannot elaborate a plan for restructuring in the stead of a hospital.
Can you, for instance, change an order to ensure accessibility, and thus force a hospital to undergo restructuring?
Yes, exactly. I can say: I want and need to treat such patients here, and other diagnoses can be treated elsewhere. But of course, how a hospital organises the provision of the needed services is a responsibility of hospital management and its owners or founders, not of the health insurance company.
The healthcare sector is preoccupied with the reimbursement ordinance and the new DRG system; what significance do you give these tools in terms of the unsatisfactory structure of hospital care?
We are now discussing long-term trends, such as a change in the spectrum of diseases, the possibility of treating patients outside of a hospital, or the centralisation of specialised care. The specific wording of the reimbursement ordinance or the concrete version of the DRG system will not affect these trends in the long run. The reimbursement ordinance, however, must not prove to be an obstacle.
The last Prague International Health Summit dealt with the management of chronic diseases, and this year’s theme is the hospital of the 21st century. If we combine both themes, the following question arises – can you list examples of chronic diseases that were previously treated primarily in hospitals and can now be handled in ambulatory care?
If I go back to the time when I worked as a doctor of internal medicine, then I recall one female patient who was admitted every six months for a period of two to three years for heart failure simply because she did not duly take her medicine. Congestive heart failure is a typical example of a disease that requires good patient preparation before they are discharged from the hospital. Once a patient is discharged, they must be immediately assumed by someone in ambulatory care. To be specific, it is ideal if patients with chronic congestive heart failure weigh themselves every morning. It is obvious that at the moment that they begin to rapidly gain weight, their bodies are retaining water and sodium, and their illness is beginning to become decompensated. If this is discovered in time, it can be still managed using ambulatory care and hospitalisation is not necessary, as it is needless, costs money (of course), and also leads to a worse prognosis for the patient. The better planning of patient discharges is something that can be done relatively quickly. If on the disease development timeline we should wish to begin working with preventive measures, and, for example, not allow diabetics to develop cardiac complications, kidney complications, sight disorders, etc., then this is a somewhat more complex matter. It takes a lot of work, but for instance, in Slovakia, the Dovera Health Insurance Company invested in the disease management of diabetes several years ago. And I am convinced that especially in relation to the redistribution among Czech health insurance companies in effect since the beginning of 2018, which takes patients with chronic diseases into account, we, too, shall be witness to similar programmes of integrated care for the chronically ill.
MUDr. PAVEL HROBOŇ, M.S.
Physician and economist; graduated from the Second Faculty of Medicine at Charles University in Prague, and from the Healthcare Management programme at Harvard University. For three years, he was the Deputy Minister of Health responsible for Health Insurance, Drugs, and Healthcare Products. In the period of 2002 until 2005, he worked for the Universal Health Insurance Company of the Czech Republic as a consultant and as Strategy Director. He was a consultant for the international consultant firm McKinsey&Company in several European countries in 1998 – 2002, working on projects in the fields of healthcare and financial services. He has lectured on the economics of healthcare at Charles University, and worked as a doctor of internal medicine for several years.