Specialty planning in hospitals

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

Abstract

The 2005 Health Law has assigned the National Board of Health (BoH) new functions in relation to setting requirements for hospital specialties. As a first step, the BoH has initiated a process for the planning of acute services in the five regions. The requirement that acute service hospitals provide 24-hour cover in a minimum number of specific specialties means that the number of acute hospitals has to be reduced from 40 to 20-25. In return, pre-hospital acute services will be improved.

Purpose of health policy or idea

As a result of the 2005 Health Law, the Danish Board of Health (BoH) has been assigned new functions in relation to setting requirements for approval of hospital specialties as well as their geographical placement. The BoH could previously only give advice and recommendations. A key aim of the 2005 law is to enhance the quality of health services, and there is an underlying assumption that quality can be improved by ensuring a high volume of patients, resulting in greater experience in treatments within a specific specialty. According to a report from the BoH, if a trade-off is required between service quality and geographical closeness, then quality should get priority.

As a first step, the BoH initiated a process for the planning of acute services in the five Danish regions; this plan covers both acute services provided outside hospitals and the acute reception of patients at hospitals. At present, there are about 40 hospitals (in a country with 5.3 million people) with accident and emergency departments and/or acute reception. Far from all of these hospitals offer a full-scale 24-hour coverage of the most needed specialties, and to be able to ensure this the number of hospitals with acute service has to be reduced substantially (to about 20-25 according to the BoH, which recommends a population basis between 200.000 and 400.000 per acute hospital to get a sufficient volume). The reason for this reduction is resource constraints, both in terms of budgets and manpower. As a consequence, the pre-hospital service shall be strengthened in order to offer an early life-saving and specialised treatment in spite of a longer distance to the nearest acute hospital for patients in some areas.

The initiative focuses on somatic patients, but psychiatric patients should also be included in the actual planning. As there is only sparse international or local documentation as to the optimal solution for acute services, the recommendations in the BoH report are to a certain extent based on judgements and common sense. It is envisaged that the implementation can take place over a span of years, maybe 5-10 years. 

To strengthen pre-hospital services, the BoH provided a number of recommendations, including:

• a single telephone number giving access to general practitioners' services outside their normal office hours
• measures to ensure coordination between various involved bodies, such as the alarm center, general practitioners (or their  control room for out-of-hours services), ambulance services and the hospitals' acute reception; moreover, personnel at alarm centers should receive a minimum health education, and relevant information from the alarm center should be sent electronically to the health care system
• greater use of telemedicine and better coverage with ambulances manned with doctors
• inter-regional cooperation to establish helicopter services manned with doctors for areas that lie far from a hospital (islands in particular). 

To strengthen the acute reception of patients at hospitals, the BoH provided further recommendations:

• the acute hospital should have at least five key specialties on duty 24 hours a day, namely internal medicine, orthopaedic surgery, general surgery, anaesthesiology with an intensive care department, diagnostic radiology and clinical biochemistry
• hospitals providing delivery services should have services in gynaecology, obstetrics and paediatrics available
• other specialties may also be present, and doctors from specified specialties should be on duty and easy to reach with short notice. 

The reform has been initiated by the National Board of Health, but regions are required to present suggestions for solutions in each region before the end of 2007.

Main points

Main objectives

The main objectives are to strengthen the quality of acute services, provide continuity of patient treatment regardless of time and place, and ensure efficient use of scarce resources. These objectives will be achieved by ensuring the presence of five basic specialties 24 hours a day and improving pre-hospital services for acute care (ambulances manned with doctors, helicopters). As a consequence, the number of acute hospitals will have to be reduced; regional plans regarding the geographical distribution of acute hospitals will be approved by the BoH in early 2008.

Type of incentives

No incentives are imbedded.

Groups affected

Regions, hospitals, patients

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

The policy appears to be a necessary consequence of patient demand for high quality in acute care.

Political and economic background

As of January 1st 2007, the former 15 counties were re-aligned to form five regions. As a consequence hospital planning can take place within a broader area rather than sub-optimising within the smaller counties. With the new Health Law the central authority (BoH) has obtained a greater influence over hospital planning.

Complies with

The government's "Quality Reform", presented in August 2007

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The policy originates from the report of the Structure Commision (2004), which argued for a reorganisation at the regional level, in particular because the former counties were considered too small to allow optimal hospital planning. The initiative has come from the BoH, which is a governmental body under the Ministry of Health. The Danish structural reform means that planning can take place within larger geographical areas, while improvement in the quality of health care fits with the government's aim to improve the quality of all public services.

Initiators of idea/main actors

• Government: The reform of acute health care services has not been a parliamentary issue, but a consequence of the Health Law that allowed for revisions in the planning of hospital specialties. There has been a heavy dispute within each region. The proposed regional models differ and will have to be discussed further before the final decision is made. City councils have voiced opposition to the reform in areas where hospitals are likely to be closed down. Civil society is most interested in short waiting times for ambulances. There has been opposition to the reform in areas where local hospitals are likely to be closed down.

Approach of idea

The approach of the idea is described as:
new:
amended: The health Law was prepared in 2005 with rules about planning of specialties in force from January 1st 2006.

Stakeholder positions

The reform is a consequence of recommendations from the government's Structure Committee, and these were accepted by the Parliament. The main issue was not hospital planning per se, but rather the size of regions to be established.

Actors and positions

Government
Minister of Health	very supportive		strongly opposed
Regional governments	very supportive		strongly opposed
Municipal governments	very supportive		strongly opposed
Health professionals	very supportive		strongly opposed
Civil society	very supportive		strongly opposed

Influences in policy making and legislation

The Health Law (2005) allowed for revisions in the planning of hospital specialties, with the BoH playing a strong role.

Actors and influence

Government
Minister of Health	very strong		none
Regional governments	very strong		none
Municipal governments	very strong		none
Health professionals	very strong		none
Civil society	very strong		none

Positions and Influences at a glance

Expected outcome

The reform is expected to achieve its objective of increasing quality in acute care. Cost consequences will probably be neutral. An undesirable effect may be longer distances to an acute hospital for patients in certain areas of the country, including inhabitants of islands.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

It is likely that a number of smaller hospitals will close. This has been an ongoing process, which this reform will enhance.

References

Sources of Information

Indenrigsministeriet : Strukturkommissionens betænkning. (Ministry of Interior: Report from the Structure Commission).  Betænkning nr. 1434, 2004. www.im.dk/publikationer/strukturkom_Bind_I_/index.htm

Sundhedsstyrelsen: Patienter skal sikres den bedst mulige behandling (National Board of Health: Patients should be ensured the best possible treatment). Copenhagen, 2007. www.sst.dk/publ/Publ2007/PLAN/Specialeplanlaegning/Bedstmuligebehl_pjece_jan07.pdf

Sundhedsstyrelsen: Gennemgang af akutberedskabet. (Board of Health: Overview of the acute readiness), Copenhagen, December 2006. www.rm.dk/files/Metteb/pdf-ermm/Akutberedskab%20rapport%20211206%20til%20h%C3%B8ring%20(4).pdf

Author/s and/or contributors to this survey

Christiansen, Terkel

Web site: www.healtheconomics.org

Suggested citation for this online article

Christiansen, Terkel. "Specialty planning in hospitals". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/dk/a10/5