regional responses to demographic challenges how can health and social care be affordable in the...
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Regional Responses to Demographic Challenges
How can health and social care be
affordable in the future?
Barrie Dowdeswell
Executive Director
European Health Property Network
Context
Health costs are rising at 3 to 4 times general inflation GDP growth is slowing or stagnating Increased health spending (generated by an explosion
in technologies and expectation) is increasingly funded by borrowing
This now looks unsustainable Across Europe governments are applying an
increasing range of cost saving measures Age related care represents about 40% of ‘embedded’
spending - but ‘cuts’ are indiscriminate We are only at the start of the cost surge generated by
an ageing population
Demographic transition in Europe - why effective management is critical
It defines societal and professional values
Sustaining economic growth (viability) The changing economic balance and GDP, regional, national
and European strategies The pension time bomb
Reducing the cost burden of healthcare Affordability From cost to investment
Shaping future service and capital investment
What the EU ‘Communication’ says
The proportion of the total European population older than 65 is set to increase from 16.1% in 2000 to 27.5% by 2050; over 80 years (3.6% in 2000) is expected to reach 10% by 2050
Public health (direct) care expenditure could increase by between 1.7 and 5.3 GDP points in the period 2000-2050.
THREE LONG-TERM OBJECTIVES: ACCESSIBLITY - a right to care enshrined in the Charter of
Fundamental Rights of the European Union QUALITY - achieve an optimum balance between the health
benefits and the cost of medication and treatment VIABILITY - to ensure the affordability of high-quality health
care that is accessible to the population
The Netherlands - trend lines
number of aged persons (65+) per profile
0
50.000
100.000
150.000
200.000
250.000
300.000
2007 2010 2020 2030 2040 2050
prof 2
prof 3
prof 4
dementie
estimated capacity (bases on CBS 2007)
0
50.000
100.000
150.000
200.000
250.000
300.000
2007 2010 2020 2030
nursing homes
assited elderly living
adapted housing
The Netherlands - capacity forecasts, not just a matter of counting
Current capacity (2005) in elderly care, 170.000 beds
The (health) rationale of the EU
Life expectancy Disability free life expectancy Yrs Yrs
UK 2.2 1.2
France 2.3 2.7
Netherlands 1.5 4.3
“Good and equal health is a human right”
Gains in life expectancy (LE) - males - per decade
The silent epidemics Musculo / Skeletal degeneration - e.g.
Osteoporosis; a factor of frailty and risk In 2000, estimated number of osteoporotic fractures in Europe
was 3.79 million. Total direct costs resulting estimated at €31.7 billion which are expected to increase to €76.7 billion in 2050.
24% women, 33% men die within one year of fracture Neurological disease and degeneration - e.g.
Alzhiemers; a factor of increased dependency Estimated number of people living with dementia in the EU is
between 5.3 and 5.8 million people. - between 1.14% and 1.27% of all citizens.
Set to double in Western Europe and treble in Eastern Europe by 2050
We are also seeing the emergence of early ageing chronic disease e.g. diabetes
Gradation of hip replacement across Europe - plus cost projections
Mediterranean Eastern Mid Northern Europe
20
16
12
8
Per 10,000 pop
2010 2020 2030 2040 2050
75
60
50
40
35
Billions euro
Capital investment (Scanners) / quality relationshipit is not how many - but how effectively used
9 months One week 4 months
Waiting times
Scanner range 1 to 30 per million populationEuropean recommendation 10 to 12 per million
1
30
Epidemiological and Demographic transitions - the two critical influences - third age issues
HospitalHospital
Public Health- 1950
Acute Care1950 -2008 ?
Chronic Illness 2005 -
AgedCare2010 -
Community&,
lifestylesupport
PPPDiversity
Re-emergence &revitalisation
Compressionimpact
Healthyageing
The evidence for change - the easy options
Region 1
Region 2
Trust BTrust
1Trust 2 Trust 3 Trust 4 Trust 5
Technical Efficiency Issues
ALOS and DCR 10% better than national averages
10% 9% 9% 6% 8% 9%
Allocative Efficiency Issues
Reduced repeat admissions
12% 11% 10% 11% 10% 14%
Total bed days saved 22% 20% 19% 17% 18% 23%
Ref: Degeling, CCMD, Durham 2006
Hospitalisation of the chronic ill and elderly Studies show high levels of inappropriate hospitalisation - between 25% and 40% - almost universal across Europe
The reasons are: Lack of knowledge and data about the problem Lack of suitable alternative provision Absence of systems to integrate care e.g.
Care pathways Funding systems and strategies
Lack of incentives for change Perverse performance targets Conventional planning and design standards, and systems do not measure up
In the main capital investment in healthcare remains dominated by acute hospital investment - a continuation of a hospital-centric model of care - changing priorities is ‘risky’
The level of change needed is masked by the acute hospital default problem
Why the Capital dimension is important It conditions the locus and focus of care It shapes long-term patterns of service expenditure The opportunity costs are rarely defined Decades of high tech ‘warehouses’ have conditioned
thinking and design There is significant asymmetry between service
strategy and capital asset delivery (the 5 to 10 year gap)
Acute hospital investment has achieved iconic status Evidence based change is difficult - in the absence of
good and reliable evidence New capital injection is the major stimulus for change
The capital investment and planning conflict in Europe
Service outcome evidence Benefits of planned predictive integrated care pathways
Capital investment outcome evidence Benefits of care pathway based planning and design to achieve
more responsive and adaptable buildings - there is good evidence to show significant bed reductions are viable and necessary
Ideological trends Towards segmented market led health strategies and business
driven PPP (capital) models - e.g. the NHS £80 billion PFI capital debt
Whole Systems Model - the need for change
Capacitymodel
Whole systems
Acute
Acute
IntermediateP.C.
Centre
intermediate P.CCentre
LongStay
Long Stay
Individualinvestment
Portfolio / Integratedinvestment
Direction ofReform ?
The problem for the Region
Increasing waiting times for treatment and increasing costs Health inequalities Shortage of capital Duplication of services
The problem for the hospital
Poor quality outcomes Rising demand, the early impact of an ageing population Competing for capital Danger of losing staff
Coxa, a case study – the problems (typical of many health systems)
Concept – quality driven integrated systemised care
Home Community Hospital Intermediate Residential
Regional Joint ReplacementService
Organisation Funding Incentives Outcomes Systemsintegration
Organisational and funding focus
Care pathwaysCOXA DESIGN CONCEPT BASED ON SYSTEMISED CARE PATHWAYS
The underlying principle - systemised care concept
Care pathways describe predictedtreatment and care processes andresource implications
The impact of technology
A major change factor
Technology as an agent of changing health systems and structures
COXA whole service / capital integration
CPs
Theatre check in
Diagnosticprogramming
Recovery / rehab prog
before
after
theatre
ward and diagnostic ward
Coxa Hospital and patient flow, 90+% compliance with care programme- the equivalent of 30% bed reduction
Each patient has a normative predictive treatment and care protocolthat provides an agreed standard across all agencies in the region
Throughput increase, 1494 in 2004 to 3,500 in 2007
Activity performance 3 day stay (including hip replacements) 90% same day operation – all have pre-planned pathways 70% of patients are transferred for rehabilitation to primary care led
facilities and services – others to local hospitals
complication (infection) rates < .1%
“outstanding” for workforce and patient satisfaction
Financial performance has allowed 10% Price reductions in 2008 Self-financed sustainable capital development
Performance
Critical success factors Defining the problem Designing an optimal solution - applying
new knowledge and technology Whole systems engagement of:
Regional and municipal governments Former competing hospitals
Region wide systemised care pathway structures - as the precursor to change
Capital investment as a catalyst for change Public accountability and transparency
Rhoen Klinikum, Germany – Corporate Aim: Quality through standardisation, service volumes & adaptability
Emergency
Diagnosis
Theatres
Hot floortechnologies
High intensity care
High levelcare
General care
Rehab
Patient treatment and discharge pathway
Communityportal
Polyclinic
Quickerand better community
support
A wholly integratedmulti-disciplinary model
Core principle - progressive patient flow, multi-discipinary systemised care pathways, design synergy
The whole systems technologies are here now - off the shelf
A campus concept in developmentSittard Netherlands, Central Sydney, Aus- reconfiguring the hospital system
Technology ‘hub’ hospital
Polyclinic
‘Factory’units
Patienthotel
Primary care
Facilities have modularcharacteristicsto provideflexibility
New ICT technologies e.g. telemedicine allows many of these to be dispersed
Elderly &Home units
The design revolutionfrom the monolith model
To the - adaptablemodel
New functional / adaptable model
Hot floor Hotel Office industry
Model A Model B Hotel Hot floor Office Industry
useful floor area (m_) 29.597 29.597 6.094 13.733 7.235 2.535
gross / useful 160% 156% 163% 156% 153% 150%
gross floor area (m_) 47.355 46.177 9.912 21.423 11.051 3.791
floors 4 4,5 4 2
height of floor (m) 3,75 3,3 3,75 3,4 3,75
footprint 11.360 2.430 4.520 2.620 1.790
€/m_ 1.500 1.397 1.370 1.454 1.127 1.931
costs (mln.) 71,0 64,5 -6,5 -(9%) 13,6 31,1 12,5 7,3
Difference
-1.178
Properties and construction costsNew Model
- (9%)
The long-term benefitIs lifecycle adaptability
Cost saving
Wiegerinck architecten
Zutphen – Gelre Ziekenhuizen
hot floorindustryoffice
hotel
The dynamics of change – increasing community focus
Localiseddiagnosis
& care
Hospital networks Community
services
hospital
£ and staff are relatively mobile
New regional strategies to integrate primary, acute care and social care:• diagnostic and treatment portals• hospital networks• polyclinics• whole systems integration using new ICT highways
Reducedtreatmenttime / need
e.g - the new Karolinska, and Skane Region ‘nearby care’ strategies
Societal Icons but how well will they support an ageing population; what are the alternatives
Insight x Knowledge x Values = Vision for the Future
Conclusions (capital investment indicators) - we are not moving fast enough
The continuing problem of a hospital centric healthcare model - the political will to change
Lack of awareness of: The nature, scale and immediacy of the problem The challenge to sustainable, affordable healthcare The importance of the economic dimension
Problems of establishing crosscutting, integrated planning and investment - and incentives
Slow diffusion of new thinking and knowledge: Interlinked (whole systems) service and capital investment ICT (Digital) revolution New concepts in hospital design and financing
Missed opportunities for using structural aid funding to support EU objectives for the elderly
Old people are us - but later
Each of us faces the probability of becoming dependent on the help of others when we get older
A Dilema
Should there be a moratorium on new acute hospital capital spending until better (and more) community facilities and services are in place to facilitate relevant reductions in hospital beds numbers The EU average is 4.1 beds per 1,000 Netherlands is planning 2.3 Some commentators suggest under 2 if primary
and social care is better developed What problems would this generate