This is part two of the analytical material “Prospects for Small Hospitals in the Context of Medical Reform”. If you are interested in part one, please follow this link.
Have you ever experienced that the expectations and needs of patients are not met due to various barriers, financial or organisational, or due to medical services fragmentation? And therefore, patients had access to only a certain part of the necessary medical care?
This situation is quite typical. And despite the fact that it happens often, we hardly ever notice it. The insight comes when some close person, a healthcare professional or municipal official is at the centre of events. This provides an opportunity for an internal view of the services organisation rather than an external one.
An integrated healthcare system is focused on the patient's needs, rather than on the diagnosis or disease. These needs often go beyond the disease itself, and beyond the healthcare system (hereinafter referred to as HC), closely intertwined with the related sectors, such as social, education, culture, law enforcement, etc. For example, an elderly patient with osteoporosis (an increased risk of fractures due to fragile bones) requires, apart from treating the disease itself, a living environment assessment with recommendations to reduce the risk of falls, training in proper walking and fall prevention skills, as well as educating relatives on how to care for the patient.
Municipality-level integration always has to do with the list of medical services in demand in the given municipality. Some of them may be available at the municipality level, while others may not. As a result, this would require the development of patient pathways and the formation of partnerships with a wide range of stakeholders. The basis of any integrated HC system is the primary healthcare service, which plays a key role in developing a person-centred approach and should be represented in every municipality. However, there are numerous other medical services to some extent in demand within the municipality. Therefore, during strategic planning, it is critical to have a clear understanding of what exactly and to what extent the municipality residents need. This understanding should form the basis of the healthcare development strategy, planning of the HC facilities network and the list of medical services at the municipality level.
The ideal situation is when a team of municipality executives at a strategic session comes to a common understanding that some of the healthcare services demanded in their municipality need to be provided, and this requires certain changes (logistical and/or personnel) to the functionality of the existing hospital. And not vice versa, when a decision on the need for a hospital is made first, and only then do they determine what services to provide there.
According to the experience of European countries, the services that are most often provided in small hospitals are rehabilitation and restorative treatment (after early discharge from intensive care hospitals). They make up the lion's share of services at the level of such hospitals, along with palliative and hospice care, emergency departments with trauma centres, outpatient consultations with speciality physicians, diagnostic services, geriatric and social beds, multidisciplinary mobile teams, mental health services, same-day surgery, etc. Often, nurses are the key staff members, sometimes even without doctors in the HC facility at all, so-called nursing hospitals.
As a rule, such hospitals serve one or more municipalities with a total population of 15–20 thousand people and above. The average number of beds in municipality-level hospitals in England is 28 per provider. The average length of hospital stay is approximately 28 days, and the cost of stay is several times cheaper than in an intensive care hospital. Almost 50% of patients who are discharged from intensive care hospitals early end up there for recovery and rehabilitation.
Thus, the main purpose of small hospitals is not intensive treatment, but recovery and care. This is reflected in the list of services provided there. Often, these hospitals are home to powerful multidisciplinary teams that provide comprehensive patient care, including the involvement of related specialists:
speech therapist, psychologist, social worker, etc.
The story of the railway hospital of the Vapniarka municipality (Vinnytsia Oblast) is a great example.
It was an inpatient department of the routine treatment of the railway hospital, which served railway employees. In 2015, the hospital was transferred from Ukrzaliznytsia's balance sheet to the municipality. The maintenance of the hospital, including the salaries of the remaining staff, required approximately UAH 5 million per year, putting a significant burden on the local budget. Accordingly, the Vapniarka municipality considered several options for its re-profiling. It is worth noting that at that time the hospital remained in a catastrophic state. The municipality carried out some of the most necessary repairs, renewed the cancelled licence for medical practice and hired doctors. However, due to the requirements of the National Health Service of Ukraine, the institution could not sign a package under the MGP (Medical Guarantee Programme), only a primary healthcare package. Subsequently, a municipal institution, the Centre for the Provision of Social Services, was established on the basis of this facility. Almost 20 former hospital employees joined the Centre, and 15 retired. The Centre currently provides a wide range of services: from physical rehabilitation to organising leisure activities for the municipal residents. Medical services include physical therapy, X-ray examinations, electrocardiography, laboratory tests, etc. The hospital's services have thus evolved from purely medical to social and medical. This facility now reports to the social services department of the Vapniarka municipality, although it has a family doctor and four nurses in the staff. The cost of running the centre reaches UAH 2 million a year, 2.5 times less than the previous hospital cost the budget. The municipality's immediate plans include the creation of a 24-hour palliative care facility on the basis of the territorial centre, which will eventually rely on state funding.
Conclusion.
A challenging question: “Do municipalities need small hospitals?” is rather rhetorical. There are no easy answers to it. The right answer comes only after a comprehensive analysis of the needs of the population, all threats and opportunities, strengths and weaknesses. This answer should rely on real data, rather than on some people's theoretical vision or political ambitions. The cornerstone should therefore be the development of an integrated HC system that comprehensively addresses human needs through broad cross-sectoral collaboration of qualified personnel from different fields.
