Changes in the hospital care environment impacting on nurses workforce conditions a European perspective Reinhard Busse, Prof. Dr. med. MPH FFPH Dept. Health Care Management, Technische Universität Berlin, (WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies
How has the hospital care environment changed in the last 10 or 20 years? inpatient outpatient treatment in community, as day care etc. fewer hospitals with fewer beds hospitals used for severely ill and/or high-technology patients over short time spans in addition, case-based payments contributes to this development very different work environment for nurses and other health professionals What can we see and learn from European data? 2
How can we learn from data? 1. Single parameter in (e.g. number of hospital beds) does not tell us anything as we do not know whether number is appropriate! 2. Single parameter in one country over time better but still of little use (e.g.: More hospital beds better or worse?) 3. Comparison of that parameter with other countries at one point in time and over time even better 4. Correlations between different parameters, e.g. hospital beds and number of nurses, in different countries most useful but still many pitfalls Context information always important! 3
1400 Hospital beds per 100000 1200 1000 800 only few data around European average 600 400 200 1990 2000 2010 4
1100 Acute care hospital beds per 100000 1000 900 800 700 600 500 400 300 200 1990 2000 2010 better data around European average 5
30 In-patient care admissions per 100 25 20 15 PL = exception 50% increase 10 5 1990 2000 2010 6
Age standardized admission rate per 1000 population 2.4 2.1 1.8 1.5 1.2 0.9 0.6 0.3 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Different numbers of inpatients different epidemiology or differences in treatment style? Here: hospitalisations for breast cancer Belgium Croatia Cyprus Czech Republic Denmark Hungary Iceland Israel Italy Lithuania Luxembourg Malta Norway Slovenia Spain Switzerland 7 United Kingdom
% of day-cases to all admissions (2008) United Kingdom (2008) (2008) Italy (2006) Denmark (2009) Spain (2005) (2008) Malta (2009) (2008) Belgium (2007) Israel (2008) Luxembourg (2007) (2008) Switzerland (2008) Norway (2009) Cyprus (2008) Slovenia (2007) (2008) Hungary (2008) (2008) Lithuania (2009) Czech Republic (2008) (2008) Inguinal hernia repair: % as day cases 0 7 14 21 28 35 42 49 56 63 70 8
% of day-cases to all admissions 70 63 56 49 42 35 28 21 14 7 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Belgium Croatia Cyprus Czech Republic Denmark Hungary Israel Italy Lithuania Luxembourg Malta Norway Slovenia Spain Switzerland 9 United Kingdom
20 Average length of stay, all hospitals 15 10 5 1990 2000 2010-50%; now 3 days below European average 10
500 Physicians per 100000 400 300 200 PL = exception no increase 100 1990 2000 2010 11
1700 Nurses (PP) per 100000 1600 1500 1400 1300 1200 1100 1000 900 800 700 600 500 400 300 Rate below European average and no increase! 200 1990 2000 2010 12
150 Nurses graduated per 100000 100 50 0 1990 2000 2010 Increase from very low level; but still below European average 13
200 Y Nurses newly graduated per 100000 population Y = 0.03709X+9.2 Today (i.e. latest avalaible year) 150 100 50 0 ALB Rate above replacement LAT PT SK PL FR SWE NL GER FIN IRL Rate below replacement 0 500 1000 1500 2000 X - Nurses (PP) per 100000, Last available Y - Nurses graduated per 100000, Last available Nurses per 100000 population X 14
500 Y Physicians per 100000 population Y = 0.04856X+262.53 2000 400 300 200 100 1.3 : 1 Few nurses, few physicians PT LAT ALB 3 : 1 2 : 1 AT FR SK 2.2 : 1 PL European average GER NL SWE European average IRL FIN 6.5 : 1 Many nurses, few physicians 0 500 1000 X - Nurses (PP) per 100000, 2000 1500 Y - Physicians per 100000, 2000 X Nurses 15 per 100000 population
700 600 Y Physicians per 100000 population Y = 0.07956X+253.22 Today (i.e. latest avalaible year) 500 400 300 200 Few nurses, many physicians 1.4 : 1 LAT 2.3 : 1 ALB PT European average European average 100 0 500 1000 1500 2000 X - Nurses (PP) per 100000, Last available Y - Physicians per 100000, Last available Nurses 16 Few nurses, very few physicians SK PL 3.4 : 1 AT 2.4 : 1 NL FR SWE GER IRL FIN 6 : 1 High nurse : physician ratio X per 100000 population
1000 Y Acute care hospital beds per 900 100000 population Y = -0.01403X+492.5 2000 800 700 600 500 400 300 200 100 Few nurses, many beds PT Few nurses, few beds LAT 1 : 1 0.6 : 1 PL ALB AT FR European average SK GER 3 : 1 1.7 : 1 NL SWE 1.5 : 1 European average 6 : 1 FIN High nurse : bed ratio IRL 0 500 1000 1500 X - Nurses (PP) per 100000, 2000 Y - Acute care hospital beds per 100000, 2000 X Nurses 17 per 100000 population
1500 Acute care hospital beds per 100000 population 1000 500 0 Few nurses, many beds 1 : 1 LAT ALB European average AT PL SK FR PT 2 : 1 2 : 1 GER 1 : 1 3.5 : 1 NL SWE 8 : 1 European average IRL FIN Today (i.e. latest avalaible year) High nurse : bed ratio Few nurses, few beds X 0 500 1000 1500 2000 X - Nurses (PP) per 100000, Last available Y - Acute care hospital beds per 100000, Last available Nurses 18 per 100000 population
30 25 High 20patient : nurse ratio 15 10 5 0 Y Inpatient admissions per 100 population 50 : 1 PT LAT 30 : 1 PL ALB Y = 0.008209X+10.46 AT SK European average 25 : 1 GER SWE NL 10 : 1 FIN 20 : 1 European average IRL Low patient : nurse ratio 0 500 1000 1500 X - Nurses (PP) per 100000, 2000 Y - In-patient care admissions per 100, 2000 X 2000 Nurses 19 per 100000 population
50 Inpatient admissions per 100 population 40 High patient : nurse ratio 30 20 10 0 40 : 1 LAT ALB 40 : 1 PL AT SK PT 40 : 1 = European average FR 22 : 1 GER NL SWE 10 : 1 = FIN 15 : 1 European average IRL 9 : 1 Low patient : nurse ratio 0 500 1000 1500 2000 X - Nurses (PP) per 100000, Last available Y - In-patient care admissions per 100, Last available X Today (i.e. latest avalaible year) Nurses 20 per 100000 population
Costs and cost components by country: Hip replacement
Costs and reimbursement by hospital within country: Hip replacement 12000 10000 Reimbursement (Euros) 8000 6000 4000 2000 and Hungary Denmark England Hungary Italy Spain 0 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 Total cost (Euros) 22
395,97 1025,76 1861,02 2465,32 2866,36 5013,64 5916,45 5599,30 7450,22 308,88 592,15 2236,40 2868,16 5369,53 483,05 1415,79 2541,845 2733,38 8282,36 6225,55 1181,53 1282,55 3720,88 4384,72 4161,15 7616,89 9374,21 0,00 1000,00 2000,00 3000,00 4000,00 5000,00 6000,00 7000,00 8000,00 9000,00 10000,00 Hungary (N=2) (N=5) Spain (N=5) Denmark (N=3) (N=13) England (N=3) (N=3) (N=6) Italy (N=5) in 23 Acute myocardial infarction 23
Acute myocardial infarction Working conditions likely to change a lot in future! 24
Impact of DRGs: felt or real? Hospital CEOs Medical controllers Physicians Nurses improved unchanged worsened
Conclusions It s worth looking at other countries if only to learn more about ourselves and expected future changes ( ambulatory treatment, new technologies ). 26
Thank you for your attention Analysing Health Systems and Policies