The Organization of Acute Hospitals

Service Mix. Two related factors have together exerted a substantial influence on the specific organization and service mix of acute hospitals seen in different countries and contexts.

The first is the underlying service model to which hospitals and health systems aspire; crudely, this can be considered along an axis ranging from ‘fully comprehensive’ (i.e., each acute hospital should provide a full and clearly defined range of services) to ‘fully networked’ (i.e., different hospi­tals provide quite different service ranges, supporting and complementing each other through network arrangements to ensure that a local health system - rather than any one hospital - provides a comprehensive service range to patients).

Closely linked is the extent to which local health services are systematically planned, or are driven by market forces. The ideal of specifying a comprehensive service model, and then planning and investing actively to ensure that hospitals conform to this model, has had a powerful influence on health planning in many countries.

The basis of this conceptual model was clearly stated in the United Kingdom’s Hospital Plan of 1962, but has been restated in many other countries since then: Each health district should contain a single district hospital, providing a defined set of acute care services capable of dealing with the vast majority of acute care needs that might present themselves from a defined district population (often specified in terms of an ideal or typical population size).

In this model, local acute hospitals serve a defined population as a ‘natural monopoly’ provider; patients requiring more specialized care are referred up a clearly specified referral system. Such an approach is still an important force in health planning, for example, in the recent development of district and regional hospital packages of care in the South African public health system (Department of Health, 2002). By contrast, many other systems have taken a less directive approach to the service mix offered by acute hospitals.

An individual hospital may offer whatever mix of service it believes it can sustain given likely local demand, revenue, and market factors (within certain regulatory constraints); funders or planners focus their efforts on ensuring that a full range of services are provided to a defined population (be they members of a particular insurance fund or inha­bitants of a geographical area) from a collection of different providers.

These providers might find themselves in com­petition with one another for certain services, yet mutually dependent for others. This more ‘laissez faire’ approach is a hallmark of systems with higher degrees of private insur­ance funding (e.g., the United States, urban areas of India) and/or nonstate ownership of health facilities, but also appears in many social health insurance systems (e.g., France, Germany).

Although a copious and inconclusive literature has examined the issues of competition and mar­kets versus planned approaches to health care over many years, it is interesting to note that very little attention has been paid to studying the real differences in service mix observed across different systems.

Clearly, the precise service mix of an ‘acute’ hospital will vary tremendously according to context and setting. Tertiary sub-specialists at hospitals such as Massachusetts General or University College Hospitals London provide acute hospital care; yet so does a medical officer at a district hospital in Africa, single-handedly providing medical, pediatric, obstetric, and surgical care to a rural population hundreds of kilometers from any other hospital.

Attempts have periodically been made to specify particular service packages that should be provided by acute hospitals in different countries (see NHS National Leadership Net­work (2006) for a recent exercise in England), yet such an approach cannot possibly yield results applicable in all settings.

Certain trends in overall service mix can clearly be pointed to, however. Chief amongst these has been a consistent downward trend in the number of acute hospi­tal beds available and in the duration of hospital stay across all developed economies (Hensher et al., 1999a). Acute hospitals have increasingly focused their efforts and activities on the sickest patients at the most acute phase of their illness, as technological and infrastructural advances have allowed patients to be discharged ever earlier and to be cared for safely and effectively at home.

This trend has physically reshaped the acute hospital infrastructure across Europe and North America, as bed and hospital numbers have shrunk from their peak in the 1950s. In many countries, another visible trend has been the sepa­ration ofplanned care from emergency or unplanned care. Routinely scheduled care (primarily but not exclusively surgery) increasingly takes place in different facilities (in separate theaters, wards, or even entirely different hospi­tals) to ensure it is not disrupted by the unpredictable demand for emergency care and to maximize productive efficiency.

Some writers (e.g., Herzlinger, 1997) have sug­gested that the future may lie in ‘focused factories’ - hospitals specializing in one specific condition or organ system - to generate maximum expertise and efficiency. Actual movement toward this model seems altogether more limited; indeed, single-specialty hospitals were argu­ably more common 20 years ago than they are today, as they were an important feature of Soviet bloc health systems.

Relationship with Primary Health-Care Services. It has been recognized for many years that high-quality and efficient acute care requires effective coordination between acute hospitals and the primary health-care ser­vices that provide most of us with the overwhelming majority of the health care we will require throughout our lifetimes.

The caricature of the hospital as the center­piece of the health system has - especially in developing countries - given way to an alternative caricature of the hospital as a drain on primary care, sucking resources into attempts to rescue the sickest patients and away from cost- effective primary care and public health programs.

Yet, in developed countries, a great deal of care is now delivered in community settings, care that previously would only have been delivered within an acute hospital, and much effort has been devoted to re-engineering systems and care pathways to minimize the need for hospitalization.

Developments in pharmaceutical and diagnostic technol­ogy have greatly facilitated this shift, but concerted efforts have also been made to move key staff into community- based settings. Such processes will clearly have limits at any given point in time, especially in the presence of economies of scale (see Roland et al., 2005, for a careful study of the scope for and limitations on shifting care from hospital to primary care settings in the UK). Great care and pragmatism is required when considering this issue in developing countries.

Despite their many faults and fail­ings, acute hospitals are often the most functionally effec­tive and intact components of health systems in poor countries; dismantling them in the name of primary care principles should not be advocated without the most serious consideration and technical challenge. Indeed, the idea of a deep divide between primary care and acute care is arguably an artifact of particular organiza­tional models, particularly those that differentiate sharply between primary care and hospital physicians.

Thus, in some systems, general practitioners handle primary care activity, and hospital doctors are employed by and work in hospitals - and never the twain shall meet. Yet in other systems, specialist physicians frequently practice both in the hospital and in office-based practice in the commu­nity, whereas general practitioners may well have admit­ting rights in acute hospitals, where they will admit and care for their patients using hospital resources.

The export and import of novel models of care integration often does not pay enough attention to the profound differences between systems in the underlying models of physician employment and the incentives that flow from them.