N:\EC\COM\HDS\IDP\DOCSTORE\DOCSTORE\Docs for PDF filing\Obs\Hospitals in a changing Europe.doc Hospitals in a changing Europe European Observatory on Health Care Systems Series Series Editors Josep Figueras is Head of the Secretariat and Research Director of the European Observa- tory on Health Care Systems and Head of the European Centre for Health Policy, World Health Organization Regional Office for Europe. Martin McKee is Research Director of the European Observatory on Health Care Systems and Professor of European Public Health at the London School of Hygiene & Tropical Medicine as well as a co-director of the School’s European Centre on Health of Societies in Transition. Elias Mossialos is Research Director of the European Observatory on Health Care Systems and Bnan Abel-Smith Reader in Health Policy, Department of Social Policy, London School of Economics and Political Science and Co-Director of LSE Health and Social Care. Richard B. Saltman is Research Director of the European Observatory on Health Care Systems and Professor of Health Policy and Management at the Rollins School of Public Health, Emory University in Atlanta, Georgia The series The volumes in this series focus on key issues for health policy-making in Europe. Each study explores the conceptual background, outcomes and lessons learned about the dev- elopment of more equitable, more efficient and more effective health systems in Europe. With this focus, the series seeks to contribute to the evolution of a more evidence-based approach to policy formulation in the health sector. These studies will be important to all those involved in formulating or evaluating national health care policies and, in particular, will be of use to health policy-makers and advisers, who are under increasing pressure to rationalize the structure and funding of their health systems. Academics and students in the field of health policy will also find this series valuable in seeking to understand better the complex choices that con- front the health systems of Europe. Current and forthcoming titles Martin McKee and Judith Healy (eds): Hospitals in a Changing Europe Martin McKee, Judith Healy and Jane Falkingham (eds): Health Care in Central Asia Elias Mossialos, Anna Dixon, Josep Figueras and Joe Kutzin (eds): Funding Health Care: Options for Europe Richard B. Saltman, Reinhard Busse and Elias Mossialos (eds): Regulating Entrepreneurial Behaviour in European Health Care Systems The European Observatory on Health Care Systems is a unique project that builds on the commitment of all its partners to improving health care systems: • World Health Organization Regional Office for Europe • Government of Greece • Government of Norway • Government of Spain • European Investment Bank • Open Society Institute • World Bank • London School of Economics and Political Science • London School of Hygiene & Tropical Medicine The Observatory supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of the dynamics of health care systems in Europe. European Observatory on Health Care Systems Series Edited by Josep Figueras, Martin McKee, Elias Mossialos and Richard B. Saltman Hospitals in a changing Europe Edited by Martin McKee and Judith Healy Open University Press Buckingham · Philadelphia Open University Press Celtic Court 22 Ballmoor Buckingham MK18 1XW email: [email protected] world wide web: www.openup.co.uk and 325 Chestnut Street Philadelphia, PA 19106, USA First Published 2002 Copyright © World Health Organization 2002 The views expressed in this publication are those of the editors and contributors and do not necessarily represent the decisions or the stated policy of the participating organizations of the European Observatory on Health Care Systems. All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the copyright holder or a licence from the Copyright Licensing Agency Limited. Details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Ltd of 90 Tottenham Court Road, London, W1P 0LP. A catalogue record of this book is available from the British Library ISBN 0 335 20928 9 (pb) 0 335 20929 7 (hb) Library of Congress Cataloging-in-Publication Data Hospitals in a changing Europe / edited by Martin McKee and Judith Healy. p. cm. — (European Observatory on Health Care Systems series) Includes bibliographical references and index. ISBN 0-335-20929-7 (hb) — ISBN 0-335-20928-9 (pb) 1. Hospitals—Europe. 2. Hospitals—Europe—Administration. I. McKee, Martin. II. Healy, Judith. III. European Observatory on Health Care Systems. IV. Series. [DNLM: 1. Hospital Administration—trends—Europe. 2. Health Care Reform—Europe. WX 150 H8345 2002] RA985 .H676 2002 362.1′I′094—dc21 2001032135 Typeset by Graphicraft Limited, Hong Kong Printed in Great Britain by Biddles Limited, Guildford and Kings Lynn Contents List of figures, tables and boxes vii List of contributors xi Series editors’ introduction xiii Foreword xv Acknowledgements xvii part one The context of hospitals 1 one The significance of hospitals: an introduction 3 Martin McKee and Judith Healy two The evolution of hospital systems 14 Judith Healy and Martin McKee three Pressures for change 36 Martin McKee, Judith Healy, Nigel Edwards and Anthony Harrison four The role and function of hospitals 59 Judith Healy and Martin McKee part two External pressures upon hospitals 81 five The hospital and the external environment: experience in the United Kingdom 83 Martin Hensher and Nigel Edwards vi Hospitals in a changing Europe six Are bigger hospitals better? 100 John Posnett seven Investing in hospitals 119 Martin McKee and Judith Healy eight Hospital payment mechanisms: theory and practice in transition countries 150 John C. Langenbrunner and Miriam M. Wiley nine Linking organizational structure to the external environment: experiences from hospital reform in transition economies 177 Melitta Jakab, Alexander Preker and April Harding part three Internal strategies for change 203 ten Improving performance within the hospital 205 Judith Healy and Martin McKee eleven The changing hospital workforce in Europe 226 James Buchan and Fiona O’May twelve Introducing new technologies 240 Rebecca Rosen thirteen Optimizing clinical performance 252 Nick Freemantle fourteen Hospital organization and culture 265 Linda Aiken and Douglas Sloane part four Conclusions 279 fifteen Future hospitals 281 Martin McKee and Judith Healy Index 285 List of figures, tables and boxes Figure 1.1 The hospital as a system: opportunities for change 12 Figure 2.1 Number of hospitals per 100,000 population in the European Union, countries of central and eastern Europe and countries of the former Soviet Union 19 Figure 2.2 Hospital beds in acute hospitals per 100,000 population in the European Union, countries of central and eastern Europe and countries of the former Soviet Union 20 Figure 2.3 Hospital beds in acute hospitals per 100,000 population, selected western European countries 20 Figure 2.4 Acute hospital admissions per 100 population in the European Union, countries of central and eastern Europe and countries of the former Soviet Union 21 Figure 2.5 Average length of stay in acute care hospitals in the European Union, countries of central and eastern Europe and countries of the former Soviet Union 22 Figure 2.6 Bed occupancy rate (%) in acute care hospitals in the European Union, countries of central and eastern Europe and countries of the former Soviet Union 23 Figure 2.7 Bed-days per 100 population in acute hospitals in the European Union, countries of central and eastern Europe and countries of the former Soviet Union 24 Figure 2.8 Hospital inpatient expenditure as a percentage of total health expenditure, selected western European countries 25 viii Hospitals in a changing Europe Figure 2.9 Trends in beds (per 1000 population), United Kingdom 1977–96 26 Figure 3.1 Pressures for change in hospitals 37 Figure 3.2 Total fertility rate in selected European countries 38 Figure 3.3 Future projections of the percentage of the population aged over 65 in various regions of Europe 38 Figure 3.4 Age-standardized death rate from cancer of the lung, bronchus and trachea per 100,000 population in Finland and Portugal, all ages, 1970–98 42 Figure 3.5 Age-standardized death rate from cerebrovascular disease per 100,000 population in France, Poland, Portugal and Spain, all ages, 1985–98 42 Figure 3.6 Total expenditure on health as a percentage of gross domestic product for the Group of Seven (G7) leading industrial countries, 1960–96 50 Figure 4.1 Functions of an acute care hospital 60 Figure 4.2 Percentage of cataract extractions performed as day cases in ten industrialized countries (latest available year) 62 Figure 4.3 The possible roles of a district general hospital in a health care system 67 Figure 5.1 Inward hospital interface links 85 Figure 5.2 Outward hospital interface links 92 Figure 6.1 Theoretical long-term average cost curve 101 Figure 6.2 Observed long-term average cost curve 104 Figure 7.1 External levers to improve hospital performance 120 Figure 7.2 Cardiac surgery procedures (bypasses, stents and angioplasties) per million population 137 Figure 7.3 Cardiac surgery procedures (bypasses, stents and angioplasties) per million