HEALTHCARE ESTATES 2021 PRESENTATIONS
hospital couldn’t function without it, but it’s not necessarily a large part of the capital stock. Within that, though, it’s a short term buffer for when the rest of the system is stuck – and that’s often why we talk – for example in the UK – about having too few beds, which came up at start of the COVID pandemic, as we didn’t have enough ICU beds. It’s a statement that you can’t actually shut people and hold people in location, but it raises all sorts of questions about how many beds you really think you ought to have, and it’s not just from the Hill-Burton formula.”
Not a useful way to measure capacity
“In any event,” Stephen Wright added, “this sort of bed measurement is not a useful way to look at the real capacity of a hospital to undertake clinical work, which is what you’re fundamentally interested in.” He continued: “We’ve talked about hospitals as being important, even though a lot of health policy dogma focuses on primary care and public health, and there are two reasons for this – one is that technology development in the health sector is completely non-stop. It hasn’t ever stopped in many, many years, and will not do so for a long time to come. We need to bear that in mind, and that technology can be expensive. One of the resulting problems is that healthcare demand also rises continuously, if only because many of the payers for care do not pay for what they get, which is true in many healthcare systems across the world.”
Against this backdrop, the speaker said the hospital was ‘the place that specifically focuses that technology, by embedding capital onto that rising demand’. It thus, he argued, didn’t ‘take much of a stretch of the imagination to work out that hospitals would continue to be around’. Stephen Wright said: “Primary and community care are in fact just like hospitals; they just have less capital. So,” he asked delegates, “how do we think about what hospitals do?” Here he showed a slide of a book he had already referred to, published in 2020, Understanding Hospitals in Changing Health Systems, which he had co-authored with Antonio Durán. He said: “For the book, a group of authors got together and tried to think through what hospitals are offering to health systems. We used three central concepts to look at this – one being governance – the processes and tools for control. The second is the model of care, which is very familiar to everyone in in the health sector, and the third is the business model. Of the first, he said: “There’s been a lot written about governance; it is, however, very different from just government, or just management. It’s the whole set and framework of rules surrounding what an institution, including a hospital, is doing.”
20 Health Estate Journal January 2022
In the book, Understanding Hospitals in Changing Health Systems, which he had co- authored with Antonio Durán, the speaker said that a group of authors got together and tried to think through what hospitals are offering to health systems, using three ‘central concepts’.
The model of care
He continued: “The model of care concept is a much more familiar one, and, either at the whole system, or the facility level, is about how healthcare is actually delivered – the physical processes, things like patient pathway and clinical decisions. However,” he added, “the model of care as such is not the determining factor, despite the fact we often refer to the way healthcare is delivered. Often at the outset, it doesn’t talk either about the cost or value, and you can’t make a decision on what you’re doing in healthcare or anywhere else unless you balance how much the activity is costing you against what you think you’re getting out of it. “For hospitals, looking back over many years – in fact in
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In my involvement with the health sector, one of the things I noticed quite early on was that there are plenty of things which are done in all sorts of settings. You can do things in primary care that you can also do at hospital; how do you split those activities?
this case, centuries – the model of care can identify something real about the hospital.” Stephen Wright continued: “It used to be where you went to die, and usually did – and that was the case for hundreds, if not thousands, of years. However,” he continued, “then came a series of scientific advances, in anaesthesia, anti-sepsis, and imaging, and these were encapsulated into the hospital by means of major capital investment in four areas – imaging, operating theatres, laboratories, and the emergency department.” ‘These four’, he noted, were ‘at the core of a modern successful hospital’.”
Centripetal tendencies
Over the last 50-100 years, however, there had been ‘a set of centripetal tendencies’ that had ‘sucked care into the hospital, and, in some senses, out of other settings’. “Arguably,” he continued, “there will be some demand-led (comorbidities, NCD), societal (patient-centred care), and technical (e.g. day surgery and eHealth) changes, which will lead to some centrifugal changes. Maybe care will get cascaded out from the centralised hospital in the future, but there’s a balance of centripetal and centrifugal tendencies, and we need to know how that works out.” Turning to business models, and Stephen Wright said this ‘picked up the point that we spend a lot of money, for example, on hospitals, but don’t know what to get out of it’. He elaborated: “There’s also unexplained variation all the way across institutions and systems, and we can’t seem to make a secure connection between what we put in financially to hospitals and other parts of
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