Steve Wright Executive Director, European Centre for Healthcare Assets and Architecture (ECHAA) Doing more with less: do hospitals have to get bigger?
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The document discusses the challenges facing Mid Staffordshire NHS Foundation Trust (MSFT) hospital in England. It summarizes that an investigation found poor care quality at MSFT that led to hundreds of excess patient deaths between 2005-2008. A report concluded MSFT, with 301 beds across two sites, was too small to be clinically and financially sustainable according to NHS guidelines and standards. However, the evidence on optimal hospital scale is mixed, with most studies finding economic benefits up to 200-400 beds but little consistency on clinical outcomes related to size. Maintaining local access must also be considered in determining hospital scale and configuration.
Steve Wright Executive Director, European Centre for Healthcare Assets and Architecture (ECHAA) Doing more with less: do hospitals have to get bigger?
- 1. 1 Do (English) hospitals have to get bigger? Or, never mind the quality, feel the width… Steve Wright How can we do more with less? European Health Property Network / Architects for Health London, RCP, 20th May 2013
- 2. 2 ECHAA’s aim is - by means of comprehensive analysis - to: Support evidence-based policy on the contribution of the built environment to the European health sector Analyse, for hospitals & other healthcare facilities: the interface with services, sustainability, finance, quality & safety, & problems of transition economies Partners: DuCHA: part of TNO, the state Netherlands Organisation for Applied Scientific Research (www.tno.nl/ducha) HaCIRIC: a collaboration of UK universities – Imperial College Business School, Loughborough, Reading & Salford (www.haciric.org) Semmelweis University Health Services Management Training Centre (http://english.hsmtc.hu/site/) Aalto University (www.arts.aalto.fi/en/) Ministry of Health of the Republic of Slovakia (www.health.gov.sk/Index.aspx) European Centre for Health Assets and Architecture
- 3. 3 Signposts What was the Francis Enquiry about? Is the Mid Staffs hospital too small to survive? What does literature say about scale?
- 4. 4 Mid Staffordshire NHS Foundation Trust Mid-Staffs (MSFT) is in the English West Midlands Dual-site: Stafford District General Hospital - 301 beds, Accident & Emergency, maternity, Critical Care Unit, paediatrics etc. Built 1984. The problem facility Cannock Chase Musculoskeletal Unit - 53 beds, rheumatology, orthopaedics, day/short-stay, Minor Injuries Unit. Built 1992 Total annually: 250,000 patients, 63,000 admissions, 74,000 A&E “Surrounding area population” of 320,000, local Clinical Commissioning Groups cover 276,000 Awarded “Foundation Trust” status (~independence), early 2008 Placed in Special Administration April 2013
- 5. 5 MSFT has been thoroughly studied - & nobody likes the look of it Source: E&Y, January 2013
- 6. 6 A treatment & care scandal I apologise on behalf of the government and the NHS for the pain and anguish caused to so many patients and their families by the appalling standards of care at Stafford hospital, and for the failures highlighted in the report (Secretary of State) Negative culture in Board & management… self-promotion… dishonesty Professional disengagement by senior clinicians Patients & local community not heard Absence of an effective system of clinical governance Lack of focus on service standards Shortage of skilled nurses… completely inadequate nursing Prioritisation of finances over quality of care Failure of the commissioning, regulatory & supervisory systems Patients left in excrement.. No feeding assistance.. Water out of reach.. No assistance with toileting.. Wards & toilets filthy.. Privacy denied even in death.. Triage by untrained staff.. “Excess deaths” (calculated over Hospital Standardised Mortality Rate, at 95% CI) of 492 for 2005-2008 or 1197 for 1996-2008
- 7. 7 Some thoughts on disasters This doesn’t excuse MSFT It would be possible to have a discussion about “bad apples”, “bad barrels” & “bad barrel-makers” Complex systems (Cook, How complex systems fail): Are intrinsically hazardous Usually have multiple layers of defence, so fail only with multiple failures Always run in degraded mode, as broken systems, with proto-accidents just around the corner - & potentially visible There isn’t a root cause of failure, & the pattern of failure changes all the time Hindsight poisons the post-accident ability to recreate the pre-accident perception of practitioners Human operators have dual roles as defenders against failure - but also producers All practitioner actions are gambles What defends against high frequency-low consequence accidents may not work against the opposite
- 8. 8 Signposts What was the Francis Enquiry about? Is the Mid Staffs hospital too small to survive? What does literature say about scale?
- 9. 9 MSFT – the Ernst & Young Report This set of criteria is – of course! – in the English NHS institutional context One of the latest associated reports on the problems of MSFT was contracted by the economic regulator (Monitor) from E&Y, into the hospital’s future “sustainability” Sustainability means “deliver services to meet the needs of the present & can be maintained into the future” E&Y took 3 perspectives – operational, clinical & financial: Operational: structure, governance, risk management Clinical: performance against standards, appropriate catchment population, adequate medical staff Financial: surplus & cash generation, debt support
- 10. 10 Clinical sustainability (But somebody has to be smaller than the average - don’t they?) Further, the true population catchment, given referrals & choice, is 190-212,000 – not the c. 100,000 more reported by MSFT. Royal College Standards recommend 450-500,000 MSFT has made great strides since the failure, but it is smaller than peers, & will struggle to meet staffing needs:
- 11. 11 Financial sustainability Deficit in FY13 is £15m, within £155m T/O (largely because of extra staff recruitment made to fix the clinical problems) Although its bed utilisation is similar to peers, its relative operating costs (% of turnover) are high: To achieve breakeven in five years, the Trust needs savings of 7% of income p.a. (together with £53m of transition funding), which is judged unachievable
- 12. 12 E&Y conclusions on sustainability There is a pincer: at the English tariff, & Royal College staffing guidelines, E&Y & commentators thus argue that all English “small” hospitals are not viable: MSFT “never had a chance” 1. E&Y suggests that if a plan could be identified to deliver long term financial and clinical sustainability, then MSFT’s operating model is fit for purpose 2. But, as we’ve seen, while clinically the Trust is delivering acceptable standards of care it is supposed not big enough relative to peers to continue doing this, & financially it is insolvent 3. So there is not a credible plan to deliver sustainability over the next 5 years In sum: “Small hospitals, such as MSFT, face challenges in meeting guidelines due to having low patient volumes and as a result less ability to support the volumes of senior staff required to maintain a consultant presence 24 hours a day, 7 days a week”
- 13. 13 Signposts What was the Francis Enquiry about? Is the Mid Staffs hospital too small to survive? What does literature say about scale?
- 14. 14 Scale in hospitals is a complex subject What do we know about scale of hospitals? Amazingly, both a great deal, & not very much The literature is vast, on both clinical grounds (what is the safe level of operations?) & economics/cost efficiency (are bigger hospitals cheaper?). But the literature isn’t very good There has to be a limit to desirable scale - else in the UK the optimal solution would be a single mega-hospital (somewhere near Leeds, if you ask) While it remains true that a judgement on scale is context- specific, there is international evidence
- 15. 15 International analysis of clinical scale effects The volume-outcome relationship is not very strong. It is usually unidirectional – but at very different levels by specialty The process by which outcomes are improved in larger units is imperfectly understood – experience of individual physicians, skills of the team, availability of complementary support on-site? Definitions of high/low volume vary between studies (over a continuous range, or with thresholds?) Studies usually use in-hospital or 30-day mortality – enough? Systematic review shows that most studies are either partly or fully uncontrolled for case-mix (age, severity, co-morbidity…). When controlled, relationships diminish or disappear - & implicit volume thresholds often appear quite low Some relationships are negative! (cataracts >200/year) A realistic judgement is not at the level of the hospital, but the department or specialty or doctor
- 16. 16 International analysis of economic scale effects There is next to no international evidence that 400 beds is far from the sweet spot… “Economies of scale” apply when long term average costs fall as volume rises – probably because fixed costs are large relative to variable, & the relationship will be U-shaped Methodology for studies include hospital cost functions, econometric production functions, data envelopment analysis & survival analysis Unit of measurement should be cost per case not per day (because the first few days in a hospital are dearer) Case-mix should be adjusted Results of good studies are surprisingly consistent: Cost studies show economies are exhausted at 100-200 beds DEA shows hospitals <200 >600 beds are scale-inefficient Survival studies show optimum scale around 300 beds Denmark: “Optimal number 275 beds, 95% CI 130-585” France: Optimum between 500-520 beds
- 17. 17 What does Monitor think? (Late 2012 study by Frontier Economics/BCG) “No consistent evidence large units produce better clinical outcomes though some +ve links for specialties (surgery, cardiovascular, paediatrics)” Study repeats the evidence on cost economies (optimum size 200-400 beds; up to this range costs rise 95% for a 100% size increase) Worked cost models – showing e.g. not much cost change after 1000 births/year, no relationship at all in elective orthopaedic… Births Orthopaedic In sum, conflicting & thin evidence on economic grounds for scale effects
- 18. 18 If you thought the above was difficult enough… Confounders 1: Access The evidence for these effects isn’t compelling. A bit like that for scale advantages, in fact Even if clinical quality & productivity were better at a bigger site, the indirect cost of concentration should not be ignored. This is shifted to patients, not removed altogether There is “distance/time decay” for some issues – alcoholism & diabetes clinic attendance, lung cancer, & initial decisions to consult such as antenatal first presentation, self-referral to A&E, screening for breast/cervical cancer… Larger deterrent effects for those with low personal mobility & in particular socio-economic groups Reduced access increases mortality
- 19. 19 Confounders 2 – other factors to bear in mind “Economies of scope” (less costly per unit to produce 2 or more services in one organisation than separately) in healthcare are probably more important than scale. Emergency medicine tends to be the core here The European Working Time Directive managed to surprise the UK NHS by its arrival – it has raised the size of hospitals needed to achieve viability Mergers will probably be needed to achieve scale – these have a pretty bad reputation Integration is the Holy Grail of healthcare – the impact of scale on this should be evaluated The English tariff (“Payment by Results”) is only one part of the income stream – also PbR top-ups, SIFT (teaching & research), MFF (fiddle-factor for expensive locations “Bed numbers” is a rubbish index for capacity… The Royal College of Physicians has released a report (Hospitals on the Edge) which nowhere even mentions scale of operations!
- 20. 20 Confounders 3 – the players The dance floor could get confused… Monitor: we have already met, it has a problem (ideal hospital scale is 200-400 beds; but MSFT is too small at 300) Trust Development Authority: the dark horse of the new English NHS institutional architecture – steward for non- Foundation Trusts, including most of the basket-cases Office of Fair Trading/Competition Commission: never deployed before in healthcare but now oversees FTs – could block mergers (c.f. current review of two Bournemouth hospitals, each of 600 beds, claiming a merger needed for sustainability European Court of Justice: for the seriously legalistic
- 21. 21 Conclusions & last thoughts The Department of Health is desperate to save £20 billion, & PbR is accordingly being cut at a real-terms rhythm of 4% p.a. The system appears to be sleep-walking to kick out hospitals smaller than 400 beds: Evidence in other countries suggests these are at optimum economic scale There is a mixed international evidence base for the clinical need to increase size for many specialties (I’m not an expert here) Population access may anyway be threatened Should there not be a coherent review of hospital sustainability given both the tariff & the Royal College guidelines? Retain local hospitals when possible, & develop clinical networks when necessary… England won’t build many hospitals in coming years, but clinical/economic scale/scope issues need much better thought for any redevelopments