Reduction in the number of hospital beds

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: G-politik in Industrieländern 9

Abstract

At the end of 2006 a draft law on a ?hospital network? was produced by MoH. The idea ? considered for years ? is composed of many components, a reduction in the number of beds among others. Inefficient and/or small hospitals are encouraged to decrease number of beds as a condition for being included into the network. Hospitals outside the network would be deprived of public financing. The draft was subject to intensive discussions that led to an amended version. The process is still pending.

Purpose of health policy or idea

The majority of hospitals - which formally are autonomous - are administered by self-ruling local governments, and the Ministry of Health (MoH) has no power to influence them directly. Since there exists a surplus of hospital beds, though, the MoH pursues the reduction of beds by using financial disincentives. Ineffective hospitals, or simply small hospitals (less than 150 beds) could be encouraged to disappear from the health scene or decrease their number of acute beds and reduce personnel. An evaluation of hospitals would be produced by special commissions and approved by the Minister.

Main points

Main objectives

• Reduction of the number of small hospitals (less than 150 beds);
• Savings in recurrent expenditure;
• Consolidation and improvements in management and location of hospitals, especially in peripheries;

Type of incentives

The refusal by the payer (National Health Fund) to sign contracts with small providers (hospitals) - therefore money cannot be paid to them. Hospitals with no contracts - and money - are likely do be closed down.

Groups affected

Local populations living in areas served by hospitals which can be closed down, especially patients suffering from acute diseases, Health workforce employed in hospitals which are closed down, sacked or reduced in result of liquidation or transformation ? especially physicians and nurses.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

The idea of the "Hospitals Network" may become one of the most radical steps in a tangled history of Polish health care reform. For the first time explicit priority seems to be given to efficiency even if it can lead to losses felt by patients. Also interests of local governments and health personnel employed in small hospitals may be overcome. However, it is worrying that the reduction of the number of hospital beds is seen as the main tool to improve efficiency of the health system while ignoring long waiting list (especially in some specialties) and the lack of comfort in health care provision.

Political and economic background

The problem of a surplus of hospital beds was diagnosed and raised many times in the course of health care reform considerations. A number of political (who should assess and decide) and technical (how measure needs of care) approaches was also discussed. Many attempts to rationalize hospitals' structure (understood as reduction in number) have been undertaken However, because a very strong opposition was expected, for a long time the problem was seen as too delicate to be formally put forward. It has resulted in a petrification of the old deployment of hospital resources.   

Change of government

In the last parliamentary election (2005) the majority of political parties was very cautious while exposing their views concerning changes ? reductions ? in health infrastructure.

Change based on an overall national health policy statement

The idea of the "Hospital Network" was presented to the Parliament in the Minister's speech (7 June 2006)

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

In the past, various governments - regardless of their political color - tried to change the infrastructure in the hospital sector, mostly proposing to downsize the sector by relying on a claim that there were too many hospital beds. The situation has not been studied, waiting times analysed, but simple international comparisons concerning acute beds have been presented (the statistical category of "acute beds" does not exist in Poland). This process took the name of "restructuring" and included a number of specific projects, implemented between 2000 and 2006. It resulted in a minor reduction of hospital beds - a few doctors and nurses quitted to join the private sector - but no substantial change in their number and composition has ever been achieved.

Initiators of idea/main actors

• Regierung: The idea to reduce the number of hospitals and beds originated from the MoH.

• Leistungserbringer: Facing the prospect of closing down hospitals and having conflicting interests factions with different positions developed within the health sector.

• Kostenträger: National Health Fund has a monopolistic position while contracting services

• Patienten, Verbraucher: Access to care of patients living in areas where small hospitals may be closed down can be affected negatively (reduced access).

• Andere: Most of small hospitals which may be closed down are located in economically poor areas where they often are the largest and sometimes the only employer. Therefore local governments are very concerned about their hospitals? future.

• Politische Parteien: Before the election the party which is now in the opposition was inclined to implement even painful reforms in order to improve the general efficiency of the health system, but it has changed its position after the election.

Approach of idea

The approach of the idea is described as:
renewed: It reappeared many times but governments never explicitly proposed to reduce significantly the number of hospital beds.
amended: A streamlining and intensification of the process previously initiated under the heading of "restructuring".

Innovation or pilot project

Within institution - Under the heading of ?restructuring?, hospitals have been free to reduce the number of acute beds on a voluntary basis.

Stakeholder positions

The MoH was disappointed that it had failed to curb financial operations of hospitals which resulted in growing debts. The MoH came to the conclusion that the complex idea of a "Hospital Network" was the only proper answer to the situation. The idea covered two initiatives: a reduction in the number of hospitals (and beds) and a mechanism to guarantee stable public financing.  

The Minister of Health presented the idea of a "Hospital Network" in his parliamentary speech given on June 7, 2006.

Actors and positions

Regierung
MoH	sehr unterstützend		stark dagegen
MoF	sehr unterstützend		stark dagegen
Leistungserbringer
people employed in small hospitals	sehr unterstützend		stark dagegen
people employed in other health institutions	sehr unterstützend		stark dagegen
PHC providers	sehr unterstützend		stark dagegen
Kostenträger
NHF	sehr unterstützend		stark dagegen
Patienten, Verbraucher
patients who can be affected	sehr unterstützend		stark dagegen
patients who are not likely to be affected	sehr unterstützend		stark dagegen
Andere
local governments	sehr unterstützend		stark dagegen
Politische Parteien
coalition	sehr unterstützend		stark dagegen
opposition	sehr unterstützend		stark dagegen

Influences in policy making and legislation

In December 2006 a first draft for the law on the "Hospital Network" was presented to the public. It aroused an intensive discussion, had a significant response in professional circles and journals. An amended version was published on March 7, 2007, and the second phase of the discussion was initiated. The deadline to submit comments by all interested groups and individuals was March 20.

Legislative outcome

pending

Actors and influence

Regierung
MoH	sehr groß		kein
MoF	sehr groß		kein
Leistungserbringer
people employed in small hospitals	sehr groß		kein
people employed in other health institutions	sehr groß		kein
PHC providers	sehr groß		kein
Kostenträger
NHF	sehr groß		kein
Patienten, Verbraucher
patients who can be affected	sehr groß		kein
patients who are not likely to be affected	sehr groß		kein
Andere
local governments	sehr groß		kein
Politische Parteien
coalition	sehr groß		kein
opposition	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

At the provincial (voievodeship) level a Hospital Council, affiliated to the governmental administration, is to be set up. At the central level an analogous body is to operate. Members of both councils are to be nominated - in majority - by the government. The councils are expected to plan and coordinate deployment of hospital resources, assess hospitals' performance, and giving opinions on their future. The final decision on the individual hospital's fate is to be made by the Minister.  

Monitoring and evaluation

Institutional changes and especially the closing down of hospitals will be scrupulously monitored and the results - especially with regard to diminishing access to care - scrutinized by state and local administration. Many conflicts with local governments and local communities can be expected as well as pressure exerted by them to abandon the policy.

Review mechanisms

Halbzeitevaluation, Abschlussevaluation (intern)

Dimensions of evaluation

Prozess, Ergebnis

Results of evaluation

The change process is likely to be monitored on a permanent basis. Careful evaluation should help to conduct the change process in a rational way, that is preventing severe conflicts with local governments and communities.

Expected outcome

The general number of hospital beds will decrease and a number of hospitals will be closed down. Currently, there are 881 hospitals and 324 of them are smaller than 150 beds. It is estimated that about 200 hospitals can be liquidated, according to official suggestions. It may deteriorate access to care. However, opposition to this policy can be expected that will confine the impact of the new law.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

The problem of equity has never been appreciated among health reform leaders despite disparities in health and care utilisation existing for years. There is the risk that inequalities may increase due to the reduction in the number of hospital beds in some areas. It is also possible that the underprivileged regions, where small hospitals operate, may be affected the most.

References

Sources of Information

Health Systems in Transition. Poland, K. Kuszewski, Ch. Gearicke, 2005

www.mz.gov.pl (Icon: Siec szpitali)

Author/s and/or contributors to this survey

Wlodarczyk, W. Cezary

W. Cezary Wlodarczyk, Institute of Public Health, Medical College, Jagiellonian University

Empfohlene Zitierweise für diesen Online-Artikel:

Wlodarczyk, W. Cezary. "Reduction in the number of hospital beds". Health Policy Monitor, April 2007. Available at http://www.hpm.org/survey/pl/a9/2