Transcript L’Ospedale Nel Terzo Millenio

L’Ospedale Nel Terzo Millenio
Major Investment Planning
for the Hospital Sector
Barrie Dowdeswell
European Health Property Network
The agenda
Three themes
• European perspectives on capital
investment
• Trends in hospital investment
• The changing role of the hospital in a
regional health setting
Context - Regional devolution is now the
principal tool of reform in healthcare
throughout Europe
European perspectives - as we enter the
third millennium – investment priorities
• Most countries have not been replacing
outdated hospitals quickly enough - but
replacement will now be very different
• Governments are reconsidering the
historical focus on acute hospitals for
healthcare
• There is increasing emphasis on
alternative capital investments in local
communities
– Chronic care
– Aged care
– Mental health
– Public health
– Local community diagnosis
Needs
between 8%
and 12% of
total health
spend p.a.
European perspectives – money supply
• State ‘capital’ money is in decline
• Increasing dependency on ‘private &
commercial money’
• All loans for capital will need to be
financed out of hospital income - which
will be dependent on payment by results
• Capital investment is now moving into
the risk category – and banks have
much tougher borrowing standards
• Hospitals will need to adopt business
standards for capital management
European perspectives - capital and
population health
A strong sustained trend towards some form
of regional structural planning /
regulation
• Responsiveness to the changing needs and
values of citizens - giving people a say in local
priorities
• Using disease management (care) programmes
to plan and implement change
• Using new technologies to make care more
widely available
• Applying these techniques to rationalise services
and health infrastructure
Many
governments
are moving
from being
providers to
regulators of
healthcare
Population Health - Sustainability
“shifting health systems away from the current
emphasis on acute care towards improved
chronic and long-term care, in response to the
transitions generated by epidemiological and
demographic changes, will be essential in
sustaining a balance between affordability and
the principle of universal access”
Alexandre Kalache, World Health Organisation
Netherlands Presidency – ‘Shaping the EU Health
Community’ September 2004
The third age (transition) in healthcare
Re-emergence
&
revitalisation
Community,
Diversity
Lifestyle
Morbidity
Compression
CoMorbidities
Care
Hospital
Public
Health
- 1950
Acute
Care
1950 2005
Hospital
Chronic
Illness
2005 -
Aged
Care
2010 -
Hospitals
Patterns of change – delivering the new
hospital agenda
Three distinct models
• The centralist (national or regional
government) structure planning systems
– Northern Ireland
– Skane Region Sweden
– Tuscany
• The free markets – largely insurance fund
based
– Netherlands
– Slovakia
• Artificial markets
– English NHS
– Germany – the privatisation of public hospitals
There seems
to be a
strong trend
towards free
market
principles for
hospital
provision
Many
governments
are making it
easy for new
specialist
operators to
challenge
public
hospitals
Best in class new hospital models –
service led emphasis
• Hospital design based on care models – care
pathways – to improve the relationship between
the workforce and the working environment
• Effective clinical governance – clinical outcome
and safety audit to reinforce pathways
• A strong integrated quality ethos - including high
level focus on new threats e.g. opportunistic
infectious disease
• A premium paid for designs that
– Are adaptable
– Enhance workforce effectiveness and safety
– Create a healing environment
– Maximise the potential of new technology
This will
create new
challenges
for safety
and complex
engineering
technology
Best in class – business emphasis
• Risk management of capital investment
– Ability to service capital debt
– Ability to meet and finance changing
need – over ever shorter timescales
– Workforce responsiveness to change
• Capital financing models that provide
long-term flexibility
• Leading examples – service and
business effectiveness
• Sittard Netherlands
• St Olav Norway
• Hospital la Ribera
Spain
• Rhon Klinikum Germany
• Coxa Finland
•Northern Ireland
• ITALY – you may decide
Example - Service led-design
Average public hospital cost per case - Euro 3,870
Average RK hospital cost per case
- Euro 2,660
Multi-disciplinary
Team working
Rhone Klinikum
Public hospital
capital
element E 270
RK hospital
capital
element E 722
Technology Level 1
phase
care
Level 2
care
Rehabilitation
Progressive (care pathway) patient care
Ambulatory
follow up
Example - Service-led adaptability
• Utilising technology to manage care transitions
• Widening the scope of care pathways
Digitalised
Information
Transfer systems
External hospital networks
Digital follow up
Level 1 Level 2
Digital
Technology
Portal
phase
(community)
Technology transfer
to other settings
Rehabilitation
‘Agile space’
R.K. completely refurbish
all company hospitals on a 10 year
cycle – technology according to
return on investment, based on
Quality & Cost Effectiveness
Care pathways - European evidence
• A care pathway is an evidence based prediction of
the treatment plan for patients with similar diagnosis – it
provides a focal point for the planning and allocation
of resources, measuring effectiveness and auditing
outcomes – it is also a risk management tool
EuHPN EU 17 Country Survey –
There will be a rapid and significant growth
in patients treated within care pathwaybased protocols – an increase from 5% to
60% within 5 years
Despite the clinical, quality and planning
benefits there is little evidence that capital
planners / designers understand or use
care pathway models in State health
systems
The twin aims –
• Hospital design
and operational
effectiveness
improved by
internal
treatment (care)
pathways
• Contributing to
population
based
integrated
disease
management
pathways.
Some observed effects of cost-led capital
concepts for new hospitals
• Hybrid capital models
• Tendency towards standardised (low cost)
benchmarks resulting in poor design (there are some
exceptions)
In the 1970,s
• Appears to inhibit the effectiveness of the crucial
triangle of - workforce - work systems – design
• Underinvestment in technology
• Project decisions are often remote from the
workplace
• Cost pressure is weakening commercial interest
the built
environment
represented
75% of
project cost
Today
technology
represents
75% of
project cost
Capital models and effectiveness
preliminary EuHPN survey hypothesis
Models
PPP
Workforce
shares
*
*
PPP
Public shares
• Scale of care
pathway
based
planning
*
Independent
Not for Profit
*
PPP
Conventional
Public
Procurement
*
Co-relation to
Hospital
Infection Rates ?
• Degree of
clinical
workforce
engagement
*
PFI
low
Dominant
influence on
effectiveness
high
Sustainable lifecycle effectiveness
clinical and utility
• Supportive
capital
funding
models
Example – design and hospital infection
risk, survey of new hospital projects
Single room ratios – confidence parameter
between 50% and 100% ref. EuHPN
international ‘expert report’
• Service led models – achievement well
above minimum standard
• Cost-led models – almost all fell well
short of confidence parameters
Some
countries e.g
France,
Finland, Italy
already have
a strong
cultural
disposition to
‘privacy and
family rooms’
Capital investment in the future is about –
risk management
• Clinical risk – changes in technology and
models of care
• Workforce risk – availability, change
management
• Demand risk – markets, consumerism
and healthcare transitions e.g. chronic
care
• Political risk – policy shifts, public opinion
• Financial risk – debt servicing and
capitalisation
Implicit is
health and
safety risk
There will be
a new and
sustained
focus on cost
benefit
analysis
Risk management and Design
The key is the adaptable hospital and its
place in society
• Elasticity – demand volatility
• Functionality – changes in service type
• Sustainability – lifecycle economic value
• Transferability - technology platforms for
knowledge and treatment exchange
• High value sustainable design impact
The future
effective
lifespan of
most modern
hospitals will
be around 10
years
Refurbishment
and
adaptation
may be the
new growth
area for
capital
Regional structural planning
Why we need structure plans
• Healthcare is not a commodity it is a
fundamental societal value and right
• There is a continuing need to ensure equality and
accessibility across populations
• There needs to be controlled management of
policy shifts e.g.
– Transferring more care into local community
settings
– more progress on hospital rationalisation and
role delineation – this should not be a provider
led exercise
• Maximising the benefits of scarce resources
Pooling and
sharing
resources
within
economic
population
groupings is
the best way
of avoiding
cost-led
damage to
hospital
investment
The evidence for structural change in
acute hospitals is compelling
• 8% of average daily acute bed usage can be
saved by better primary care / hospital
integration
• 10% can be saved by concentrating specialist
expertise e.g. hip replacement
Most of these
inefficiencies
will be
overcome as
integrated care
pathways are
introduced
• 15% to 20% can be saved by providing better
chronic illness support in the community
• On average there are between 5% and 15% of
patients awaiting discharge because there are
inadequate community facilities
This does not take account of the long-term benefits
of knowledge transfer and new public health
investment – the health campus resource
This evidence
points to a
continuing
decline in
acute hospital
beds
There are plenty of integrated structure models –
changing the psychology of care
Regional
knowledge
centres
The benefits
of the best
centres of
excellence –
delivered
locally
ICT based
technology,
information and
knowledge
pathways
Community
hospitals
Specialist
centres
Polyclinics
Community
resource
centres
Technology based
equality of care for
all citizens
Home support
E health
1
Population size
1 million
We need structural coherence
Hospital free for all
contestable choice
OR
‘tariff’ based contracts
Structural frameworks
Acute
Core
Chronic
services networks care
Markets
Cataracts
Hips
Making the capital system work better
Structural planning systems and frameworks
Note:
•Most countries
have one
dimension
•Some countries
get two out of
three right
balance and
equity
Work process
based hospital
planning and design
Capital financing and
procurement models
A need for strong synergies between the
systems, and mutual confidence and
accountability between the agencies
•Few countries
match three out of
three
The issues • balancing
hospital autonomy
and efficiency
• and incentivised
regional
frameworks
Conclusion - Investing in societal capital
“Strategic capital asset planning and investment
maximizes the performance of fixed, physical or
capital assets that have a direct and significant
impact on achieving corporate objectives.
Companies and organizations depend on vital
assets to drive their business; however, they often
see them as individual, stand-alone objects
operating independently. In reality, companies are
a collection of strategic assets that exist as a single
system.”
Harvard Business School - capital investment
symposium, 2003
Health, the State and the economy
genetics
lifestyle
productivity
education
labour supply
healthcare
HEALTH
education
wealth
other socioeconomic
factors
environment
capital
formation
ECONOMIC
OUTCOMES
McKee et al LSHTM
Grazie per la vostra attenzione
[email protected]
www.euhpn.org