The Role of the Hospital in a Changing Environment Martin Mckee1 & Judith Healy2

The role of the hospital in a changing environment Martin McKee1 & Judith Healy2 Hospitals pose many challenges to those undertaking reform of health care systems. This paper examines the evolving role of the hospital within the health care system in industrialized countries and explores the evidence on which policy- makers might base their decisions. It begins by tracing the evolving concept of the hospital, concluding that hospitals must continue to evolve in response to factors such as changing health care needs and emerging technologies. The size and distribution of hospitals are matters for ongoing debate. This paper concludes that evidence in favour of concentrating hospital facilities, whether as a means of enhancing effectiveness or efficiency, is less robust than is often assumed. Noting that care provided in hospitals is often less than satisfactory, this paper summarizes the evidence underlying three reform strategies: (i) behavioural interventions such as quality assurance programmes; (ii) changing organizational culture; and (iii) the use of financial incentives. Isolated behavioural interventions have a limited impact, but are more effective when combined. Financial incentives are blunt instruments that must be monitored. Organizational culture, which has previously received relatively little attention, appears to be an important determinant of quality of care and is threatened by ill-considered policies intended to ‘re-engineer’ hospital services. Overall, evidence on the effectiveness of policies relating to hospitals is limited and this paper indicates where such evidence can be found. Keywords: hospitals; health facility environment; health care reform; organizational innovation; developed countries. Voir page 808 le re´sume´ en franc¸ais. En la pa´ gina 809 figura un resumen en espan˜ ol. Introduction of the medical professional and often leaves the outsider confused and perplexed. Hospitals pose many challenges to those undertaking Given these barriers to change, it is unsurpris- reform of health care systems. They are, quite ing that hospital reform is viewed with trepidation by literally, immovable structures whose design was set health policy-makers. Yet hospitals are a very in concrete, usually many years previously. Their important element of the health care system. configuration often reflects the practice of health care Financially, they account for about 50% of overall and the patient populations of a bygone era. Their health care expenditure. Organizationally, they incompatibility with present needs ranges from major dominate the rest of the health care system. design problems, such as a scarcity of operating Symbolically, they are viewed by the public as the theatres, to more minor problems, such as the lack of main manifestation of the health care system, as power sockets for the ever expanding number of shown by the enthusiasm with which politicians seek electronic monitors. to be photographed opening new hospitals. It is not only the physical structure that is This paper seeks to redress this information difficult to change. Hospital functions are also balance by examining the place of the hospital within resistant to change, as illustrated by the persistence the health care system in industrialized countries. It of large tuberculosis sanitoria in some countries long draws on a major study being undertaken by the after they were required. Hospitals are staffed by the European Observatory on Health Care Systems, e´lite members of the medical profession who, in which addresses a series of crucial but often many cases, can use their excellent political connec- overlooked questions. First, why were hospitals tions to oppose changes that threaten their interests. created and do these conditions still pertain? Has An environment that is technically complex, sur- the dramatic growth in knowledge and technology rounded by much uncertainty, and which contains invalidated the nineteenth-century foundations of information asymmetry, only enhances the mystique hospitals? More fundamentally, what do we mean by the term ‘hospital’ and does the designation of a building as a ‘hospital’ mean the same thing every- 1 Research Director and Professor of European Public Health, European where? Observatory on Health Care Systems, London School of Hygiene Second, if hospitals are to be integral parts of and Tropical Medicine, Keppel Street, London WC1E 7HT, the health care system, what should they look like? England. Correspondence should be addressed to this author (email:[email protected]). What size should they be? How should they be 2 Senior Research Fellow, European Observatory on Health Care distributed within a geographical area? What should Systems, London School of Hygiene and Tropical Medicine, England. they look like on the inside? How can hospitals be designed in ways that enhance their performance, Ref. No. 00-0665 Bulletin of the World Health Organization, 2000, 78 (6) # World Health Organization 2000 803 Special Theme – Health Systems both in terms of health outcomes and economic diagnosis and the recognition of new, and often performance? treatable, diseases. The massive expansion in phar- Finally, hospitals are often considered as black maceuticals transformed the management of diseases boxes when, in reality, they are complex adaptive and conditions such as peptic ulcer, childhood human systems. Why do some hospitals seem to leukaemia and some solid cancers. New specialities work well whereas others do not? How can hospital emerged, such as oncology, and common conditions performance be optimized? These questions will be such as peptic ulcer, previously treated with considered in turn. prolonged hospitalization, were managed in ambula- tory care. Whole new areas of surgery became commonplace, such as coronary artery bypasses, Why hospitals? transplantation of kidneys and other organs, and microsurgery. Hospitals, as recognizable institutions, emerged at These advances took place against a back- different times in different places, reflecting existing ground of changing patterns of disease. At least in social and, especially, religious contexts. The first industrialized countries, many infectious diseases recorded hospitals arose in the Byzantine Empire in were disappearing. General surgeons saw fewer cases the fifth and sixth centuries AD (1). Hospitals in of acute appendicitis. Orthopaedic surgeons turned western Europe emerged later, beginning in the to hip replacements, as a substitute for surgery on monasteries (2), a legacy reflected in the religious tuberculous disease of the spine, or tendon trans- designations of many present-day European hospi- plants for poliomyelitis. Thoracic surgeons, no longer tals. Most health care relied on extended families and occupied by tuberculous lung cavities, turned to the local communities, however, since formal health surgical management of lung cancer and to open services had little to offer. heart surgery. The industrial revolution brought enormous By the beginning of the twenty-first century, social changes that impacted on health and health the work of a major hospital in an industrialized care. The rapid growth of cities provided opportu- country has been transformed from that of a century nities for transmission of infections, unsafe factories earlier. The image beamed into homes throughout increased injuries, death rates rose rapidly, and social the world, in television programmes such as the supports crumbled with increasing population mo- North American series ‘‘ER’’, is that a ‘hospital’ bility. A combination of philanthropy and self- means a modern complex in which seriously ill interest among the wealthy stimulated both public patients are treated at high speed with highly technical health measures and the construction of new equipment and by skilled specialist staff. A patient hospitals. However, urban overcrowding and high with a head injury is given an immediate magnetic levels of infection often meant that going into these resonance imaging scan and is seen by a neurosur- hospitals actually increased the chance of one dying. geon who has subspecialized in intracerebral trauma. By the end of the nineteenth century infectious By contrast, a small rural hospital in a middle- disease was beginning to be understood. Semmelweis income country, providing basic care with limited showed that hand-washing could reduce the trans- facilities, could not be more different. For this image mission of puerperal fever. Lister’s introduction of we can turn to the travel writer, Colin Thubron, who antisepsis, coupled with the discovery of safe describes a small hospital in Siberia thus: ‘‘Inside the anaesthetic agents, made elective surgery safer. In building was a simple range of three-bed wards, a England, Florence Nightingale established a profes- kitchen and a consulting room. It had no running sional basis for nursing. Hospitals were now able to water, and its lavatory was a hole in the ground. offer more than basic care, but their role as a setting Between the double windows the sealing moss had for medical treatment was not yet established, and the fallen in faded tresses. It was almost without middle classes continued to have the doctor treat equipment.’’ (3) them at home. By the twentieth century, the hospital While these two images represent the extremes was beginning to take on its present-day role. of the spectrum, there is considerable diversity even Advances in chemical engineering laid the basis for within relatively homogenous health

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