Theroleofthehospitalinachangingenvironment

1 The role of the hospital in a changing environmentMartin McKee1& Judith Healy2 Hospitals pose many challenges to those undertaking reform of health care systems. This paper examines the evolvingrole of the hospital within the health care system in industrialized countries and explores the evidence on which policy-makers might base their decisions. It begins by tracing the evolving concept of the hospital, concluding that hospitalsmust continue to evolve in response to factors such as changing health care needs and emerging technologies. The sizeand distribution of hospitals are matters for ongoing debate. This paper concludes that evidence in favour ofconcentrating hospital facilities, whether as a means of enhancing effectiveness or efficiency, is less robust than isoften assumed.

2 Noting that care provided in hospitals is often less than satisfactory, this paper summarizes theevidence underlying three reform strategies: (i) behavioural interventions such as quality assurance programmes; (ii)changing organizational culture; and (iii) the use of financial incentives. Isolated behavioural interventions have alimited impact, but are more effective when combined. Financial incentives are blunt instruments that must bemonitored. Organizational culture, which has previously received relatively little attention, appears to be an importantdeterminant of quality of care and is threatened by ill-considered policies intended to re-engineer hospital , evidence on the effectiveness of policies relating to hospitals is limited and this paper indicates where suchevidence can be :hospitals; health facility environment; health care reform; organizational innovation; page 808 le re sume en franc ais.

3 En la pa gina 809 figura un resumen en espan pose many challenges to those undertakingreform of health care systems. They are, quiteliterally, immovable structures whose design was setin concrete, usually many years previously. Theirconfiguration often reflects the practice of health careand the patient populations of a bygone era. Theirincompatibility with present needs ranges from majordesign problems, such as a scarcity of operatingtheatres, to more minor problems, such as the lack ofpower sockets for the ever expanding number ofelectronic is not only the physical structure that isdifficult to change.

4 Hospital functions are alsoresistant to change, as illustrated by the persistenceof large tuberculosis sanitoria in some countries longafter they were required. Hospitals are staffed by thee lite members of the medical profession who, inmany cases, can use their excellent political connec-tions to oppose changes that threaten their environment that is technically complex, sur-rounded by much uncertainty, and which containsinformation asymmetry, only enhances the mystiqueof the medical professional and often leaves theoutsider confused and these barriers to change, it is unsurpris-ing that hospital reform is viewed with trepidation byhealth policy-makers.

5 Yet hospitals are a veryimportant element of the health care , they account for about 50% of overallhealth care expenditure. Organizationally, theydominate the rest of the health care , they are viewed by the public as themain manifestation of the health care system, asshown by the enthusiasm with which politicians seekto be photographed opening new paper seeks to redress this informationbalance by examining the place of the hospital withinthe health care system in industrialized countries. Itdraws on a major study being undertaken by theEuropean Observatory on health Care Systems,which addresses a series of crucial but oftenoverlooked questions.

6 First, why were hospitalscreated and do these conditions still pertain? Hasthe dramatic growth in knowledge and technologyinvalidated the nineteenth-century foundations ofhospitals? More fundamentally, what do we mean bythe term hospital and does the designation of abuilding as a hospital mean the same thing every-where?Second, if hospitals are to be integral parts ofthe health care system, what should they look like?What size should they be? How should they bedistributed within a geographical area? What shouldthey look like on the inside? How can hospitals bedesigned in ways that enhance their performance,1 Research Director and Professor of European Public health , EuropeanObservatory on health Care Systems, London School of Hygieneand Tropical Medicine, Keppel Street, London WC1E 7HT,England.

7 Correspondence should be addressed to this Research Fellow, European Observatory on health CareSystems, London School of Hygiene and Tropical Medicine, of the World health Organization, 2000,78(6)#World health Organization 2000both in terms of health outcomes and economicperformance?Finally, hospitals are often considered as blackboxes when, in reality, they are complex adaptivehuman systems. Why do some hospitals seem towork well whereas others do not? How can hospitalperformance be optimized? These questions will beconsidered in hospitals?Hospitals, as recognizable institutions, emerged atdifferent times in different places, reflecting existingsocial and, especially, religious contexts.

8 The firstrecorded hospitals arose in the Byzantine Empire inthe fifth and sixth centuries AD (1). Hospitals inwestern Europe emerged later, beginning in themonasteries (2), a legacy reflected in the religiousdesignations of many present-day European hospi-tals. Most health care relied on extended families andlocal communities, however, since formal healthservices had little to industrial revolution brought enormoussocial changes that impacted on health and healthcare. The rapid growth of cities provided opportu-nities for transmission of infections, unsafe factoriesincreased injuries, death rates rose rapidly, and socialsupports crumbled with increasing population mo-bility.

9 A combination of philanthropy and self-interest among the wealthy stimulated both publichealth measures and the construction of newhospitals. However, urban overcrowding and highlevels of infection often meant that going into thesehospitals actually increased the chance of one the end of the nineteenth century infectiousdisease was beginning to be understood. Semmelweisshowed that hand-washing could reduce the trans-mission of puerperal fever. Lister s introduction ofantisepsis, coupled with the discovery of safeanaesthetic agents, made elective surgery safer. InEngland, Florence Nightingale established a profes-sional basis for nursing.

10 Hospitals were now able tooffer more than basic care, but their role as a settingfor medical treatment was not yet established, and themiddle classes continued to have the doctor treatthem at home. By the twentieth century, the hospitalwas beginning to take on its present-day in chemical engineering laid the basis fora pharmaceutical industry; for example, research onchemical dyes led to the invention of began to offer cure rather than care. As thescope for clinical intervention increased, technologybecame more complex and expensive. By the 1930s,few surgeons operated on wealthy patients in theirown in military surgery in the SecondWorld War had a profound impact on hospital care,with the introduction of safe blood transfusion,penicillin, and surgeons trained in trauma greatest changes occurred from the 1970sonwards, however, with advances in laboratorydiagnosis and the recognition of new, and oftentreatable, diseases.