Data from the Health for All Database here provides the most up-to-date picture of the status of European hospital healthcare
Pascal Garel
Chief Executive
Isabella Notarangelo
Health Economist
For several years, hospitals have been required to act more efficiently and to increase productivity and, indeed, increased performance is visible. Yet, today’s healthcare systems are facing conflicting trends: short- and long-term impacts of an economic and financial crisis; increasing demand of an ever-expanding and ageing population; increasing request/availability of technological innovations.
To adapt to this situation, the role of hospitals is further evolving. Most healthcare systems have already moved from a traditional hospital-centric and doctor-centric pattern of care to integrated models, hospitals working closely with primary care, community care and home-care.
The figures given here provide the most comparative updated picture of the situation of healthcare and hospitals, compared to the situation at the beginning of 2000s. They aim to increase awareness of what has changed in hospital capacity and, more generally, secondary care provision within the EU Member States, generating questions, stimulating debate, and, in this way, fostering information exchange and knowledge sharing.
The source of data and figures is the Health For All Database of the World Health Organisation (WHO/Europe, European HFA-DB, July 2013). All EU Member States are considered, Croatia included, plus Switzerland and the Republic of Serbia (both countries have HOPE members). Whenever considered appropriate, two groups have been differentiated and compared: EU15, for the countries that joined the EU before 2004 (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, The Netherlands, Portugal, Spain, Sweden and the UK) and EU13, for the countries that joined the EU after 2004 (Bulgaria, Cyprus, Czech Republic, Croatia, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia and Slovenia). The considered trends normally refer to the years 2000–2011. When data on 2011 are not available, or if they have not been gathered for a sufficient number of countries, the closest year is considered. In general, some figures are disputed for not being precise enough but they at least give a good indication of the diversity.
Financial resources for healthcare
In the present economic and financial crisis, the impact of cuts is leading to a reduction of health expenditures. They have already started growing at a slower pace, with effects on inpatient care, out-of-pocket payment and pharmaceutical expenditure.
The amount of total health expenditure per capita in 2011 was $3231 purchasing power parity (PPP) in EU27, with wide variations around this average value: $3717 PPP in EU15, $1429 PPP in EU13.
Compared to the ten previous years, in 2011 the total health expenditure per capita has increased in all European countries. In most of them, it has more than doubled, but major increases can be highlighted in Bulgaria, Serbia, Slovakia and Romania, where it has tripled or more than tripled, and in the case of the three Baltic countries, where the average increase has been around 140% (Chart 1).
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Public sector (or general government) health expenditure includes outlays for health maintenance, restoration or enhancement paid by government entities, such as the Ministry of Health, other ministries and parastatal organisations, or by social security agencies. It includes transfer payments to households to offset medical care costs and extra-budgetary funds to finance health. The revenue base of these entities may comprise multiple sources, including external funds.
In 2011, the percentage of public sector health expenditure to the total health expenditure was higher than 65% in most countries, with the exception of Cyprus, Bulgaria, Latvia, Slovakia, Portugal and, outside the EU, the Republic of Serbia.
Between 2000 and 2011, the public health expenditure more than doubled in many EU13 countries, such as Romania, Slovakia, Bulgaria, Poland, Hungary, the Baltic countries and the Republic of Serbia, and in some EU15 countries, such as The Netherlands and Ireland. But the crisis has reduced the public coverage in several countries during the past three years.
Chart 2 shows the last-eleven-year trends in the rate of government expenditure on health. It presents the aggregate data concerning the EU, EU15 and EU13 and the figures of the three countries having the higher and the lower values, plus Switzerland and Croatia.
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In 2011, the percentages of government expenditure devoted to health differed by 4 percentage points between EU15 and EU13, being lower in the last group of countries; Switzerland shows a percentage close to 21% – rather higher and in particular growing faster – compared with the EU-associated countries.
The chart also illustrates trends. They are generally positive between 2000 and 2006 – with an average increase of percentage of government outlays devoted to health by 0.2 percentage points. Yet, from 2006 onwards, this way of development has slackened off in many countries. The reasons can be seen in the beginning of some economic difficulties in the Member States or in the shift of interests and priorities to other sectors.
In 2011, the private households’ out-of-pocket payment in EU accounted for 16.2% of total health expenditure
Private households’ out-of-pocket payment on health are the direct outlays of households, including gratuities and payments in-kind made to health practitioners and suppliers of pharmaceuticals, therapeutic appliances and other goods and services. They include household payments to public services, non-profit institutions or non-governmental organisations, non-reimbursable cost sharing, deductibles, co-payments and fee-for service.
In 2011, the private contribution to healthcare spending was around 14% in EU15 and 23% in EU13. It was higher than 30% in Malta, Latvia, Bulgaria, Cyprus and the Republic of Serbia and lower than 10% only in The Netherlands, France and the UK.
Between 2000 and 2011, the percentage of private households’ out-of-pocket payment to total health expenditure has steadily declined in the majority of European countries. It lessened by 1.2 percentage points (p.p.) in the EU and in EU15 and by 0.9 p.p. in EU13. The most relevant rates of reduction were registered in Greece (from 37.8% to 29.8%), Switzerland (from 33.0% to 25.0%), Poland (from 30.0% to 22.9%) and Cyprus (from 55.9% to 49.4%). Nonetheless, the total out-of-pocket payments in $PPP per capita continued
to increase, since the total health expenditure did.
Chart 3 illustrates the trend 2000-2011 of both the total health expenditure and the private households’ out-of-pocket payments per capita. These values do not grow at the same pace and are not correlated. The chart highlights the fast growth of both expenses in most countries of EU13 and the very low increase of out-of-pocket payment in some countries, despite an increase in total health spending of 50-80%.
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A third of health payments finance running expenses (excluding investments and capital outlays) of inpatient institutions for acute, chronic and convalescent care. Despite the fact that all funds allocated to outpatient institutions or outpatient hospital departments are excluded from this computation (because covered under ambulatory care expenses, this separation is sometimes not statistically possible for some countries), hence a quote of overlap must always be assumed.
In 2011, expenditure on inpatient care represented on average 35% of overall healthcare spending, ranging from 20% and 21% in Portugal and Slovakia, respectively, to 45% in Switzerland and 46% in Italy and The Netherlands.
In all countries even if a part of the total health expenditure is always funded by private insurances and out-of-pocket payments, almost the entire amount of inpatient health expenditure is publicly financed.
Data on expenditure on inpatient care, $PPP per capita is available for 60% of Member States plus Switzerland. For these Member States, the total expenditure on inpatient care $PPP per capita varies, on average, around 73% from 2000 to 2011. The total health expenditure in PPP$ per capita varies in the same years around 76%. Between 2000 and 2009, both total health expenditure and expenditure on inpatient care per capita increased. Starting from 2009, these figures decreased (Chart 4).
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Pharmaceutical expenditure includes the consumption of pharmaceutical products supplied on prescriptions and obtained for self-medication (often referred to as over-the-counter products), as well as pharmaceuticals consumed in hospitals.
In 2011, about 18% of the European health expenditure went to pharmaceuticals. The highest rates were registered in Hungary (33.4%), Malta (28.5%), Greece (28.5%) and Slovakia (27.4%); the lowest rates were in Denmark (6.8%), The Netherlands (9.4%), Switzerland (9.4%) and Austria (11.7%).
Between 2000 and 2011, the percentage of pharmaceutical expenditure to total health expenditure has generally declined in all of Europe. In 2011, the total pharmaceutical expenditure was encompassed between 280 $PPP per capita in Estonia and $673 PPP per capita in Greece. At least one half of it was held by the public sector in all countries except Poland (39.4%), Malta (39.5%), Italy (46.6%), Estonia (48.5%), Hungary (49.0%) and Denmark (49.2%). The highest values were Germany (75.6%), Ireland (78.0%) and The Netherlands (78.4%).
The public pharmaceutical expenditure ranged between $128.6 PPP per capita in Poland and $505.2 PPP per capita in Ireland.
Chart 5 explores the relationship between the growth of the total and the public pharmaceutical expenditure between 2000 and 2011. In this period of time, the average increase in the total pharmaceutical expenditure ranged between 40% and 75%; the average increase in public pharmaceutical expenditure ranged between 40% and 90%. In a group of outlier countries encompassing Ireland, Greece, Estonia and Slovakia, both the public and the total spending more than doubled. Only in Italy, Belgium, Slovenia and Denmark were the rates of growth of total spending lower than 40%. In Italy, Slovenia and Sweden, also the rate of growth of public outlays was lower than 30%.
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In Europe, both the total pharmaceutical expenditure and the public pharmaceutical expenditure $PPP per capita increased from 2000 to 2009 and decreased from 2009 to 2011. In almost all Member States, the total pharmaceutical expenditure decreased more slowly than did the public pharmaceutical expenditure. This suggests that a progressively larger part of the total pharmaceutical expenditure pertains to the private sector. This shift may also indicate that the “willingness to pay” and the consumption of pharmaceuticals by private owners are increasing.
Hospital capacity and delivery of care
In the past 11 years, healthcare reforms have been implemented all over Europe, aimed at rationalising the use and provision of hospital care, improving its quality and appropriateness and reducing its costs. The number of hospital facilities, as well as the number of hospital beds, have dropped off. But these reforms have also resulted in a broad reduction of acute care admissions and length of stay, as well as in improvements in the occupancy rate of acute care beds.
During these years, almost all European countries have made changes in their hospital provision patterns, major efforts being addressed to delivering better services, increasing quality, and improving efficiency and productivity. The streamlining of care delivery started from a sharp reduction in the size of secondary care institutions and moved towards more integrated and efficient patterns of care, which might in the future result in the complete overcoming of the hospital-centric model of care.
This was possible thanks to a package of financial and organisational measures addressed to improving coordination and integration between the different levels of care, increasing the use of day-hospital and day-surgery and introducing new and more efficient methodologies of hospital financing in order to incentivise appropriateness (for example, the replacement of daily payments – known to encourage longer hospitalisation – by prospective payment).
In more or less all European countries, these policies have led to changes in the management of patients within hospitals and offered a possibility for reducing the number of acute care hospital beds. Only the bed occupancy rates registered more disparate trends across Europe, depending also on the demographic and epidemiological structure of population and on the specific organisation of local, social and healthcare systems, for example, the structure of primary care, the presence and the efficiency of a gate-keeping system, the modality of access to secondary care, the availability of home care and development of community care.
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In 2011, there were on average 2.6 hospitals for every 100,000 inhabitants, ranging from 1.3 in Croatia to 5.1 in Finland. The only European Member State excluded from this range is Cyprus, where the value is around 10.2.
Moreover, there were on average 540 hospital beds every 100,000 inhabitants, ranging from 271 in Sweden to 822 in Germany.
Between 2000 and 2011, few changes in the number of hospitals were registered in Malta (-2), Hungary (-2), Portugal (-1) and Slovenia (+2). In Latvia, the rate of decrease was higher than 50%.
In the same period, the total number of hospital beds per 100,000 inhabitants decreased by about 16.1%. The only countertrend was registered in Greece, where hospital beds per 100,000 inhabitants increased by 2.8%, which means 13 new beds for every 100,000 inhabitants (Charts 7 and 8).
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In several countries, the decrease in the total number of beds was accompanied by a slight increase in the number of private inpatient beds, which are inpatient beds owned by not-for-profit and for-profit private institutions. But the share of private hospital beds – where figures are available – was still quite low in most countries, with percentages higher than 30% in only Germany, Cyprus, France, Italy and Spain (Chart 9).
Between 2000 and 2011, the number of acute hospitals decreased significantly all over Europe. 296 acute care hospitals were closed in France, 267 in Germany, 125 in Italy and 110 in Switzerland.
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The rate of acute care hospital beds for every 100,000 inhabitants in 2011 in Europe was 383. The highest figures were observed in Austria, Germany, Lithuania and Bulgaria; the lowest figures were in Sweden, Ireland and the UK.
Between 2000 and 2011, the number of acute care hospital beds per 100,000 inhabitants registered an average reduction by 18% in the EU, 20% in the EU15 and 18% in the EU13. The most significant decreases were in Latvia (-41%), Estonia (-37%), Malta (-33%), Italy (-32%) and Hungary (-26%). The only exceptions were Greece and The Netherlands, whose values increased 8% and 9%, respectively (Chart 10).
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The most relevant bed reductions were in the surgical and in the medical groups of specialties, which together represent far more than one-half of acute care beds. The reduction in the surgical specialties was around 9%, the reduction in the medical specialties was around 13%. However, it was particularly high – ranging between -20% and -40% – in the three Baltic countries and in Hungary.
The number of acute care admissions involves the entire pathway of hospitalisation of a patient, who normally stays in hospital for at least 24 hours and who is then discharged – returning home, being transferred to another facility or dying. In 2011, the rates of acute care hospital admissions in the European countries were quite dissimilar, ranging from 8.9% in Cyprus to 27.4% in Austria.
The average length of stay measures the total number of occupied hospital bed-days, divided by the total number of admissions or discharges. In 2011, the average length of stay in acute care hospitals roughly ranged from 5 to 8 bed-days.
Between 2000 and 2011, almost all countries reduced their rates of admission or at least stabilised it. Many of them were also able to reduce the length of stay in acute care hospitals, and the EU average improved, decreasing from 7.6 bed-days in 2000 to 6.4 bed days in 2010, the EU15 average improving by 1.2 bed-days and the EU13 average improving by 1.3 bed-days (Chart 11).
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The link between the rates of admission and the length of stay can be a very sensitive issue for hospitals, as it is commonly acknowledged that too short a length of stay may increase the risk of re-admissions, with a consequent waste of resources both for the hospital and for the patients and his carers. At the same time, a too high length of stay may be indicative of inappropriate hospital settlement, causing the same kinds of waste of resources as seen previously.
Chart 11 compares the rates of hospital admission and the average length of stay in 2011. The average European figures indicate a mean rate of admissions by 17.2 per cent and a mean length of stay by 9.1 days for all hospitals. The foremost variations between countries concern the admissions. A cluster of countries, encompassing EU13, present a number of admissions slightly higher than the average. The smallest countries seem to be more successful in finding a good balance between these two indicators.
The bed occupancy rate represents the average number of days when hospital beds are occupied during the whole year and generally mirrors how intensively hospital capacity is used (Chart 12).
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In 2011, the average acute care occupancy rate in Europe was 76.3%, but the gap between the highest and the lowest rates was almost 40 p.p. Between 2000 and 2011, there were inconsistent trends in Europe, the average rate of acute bed occupancy in EU decreasing by 1.0 p.p., the other values ranging between +2.8 p.p. and 9.5 p.p. in Austria and Cyprus, respectively, and -9.6 p.p. and -6.0 p.p. in Croatia and Latvia. In The Netherlands, the decrease in p.p. was about 17.1. These large variations are usually due to changes in the number of admissions, average length of stay and the extent to which alternatives to full hospitalisation have been developed in each country.
Healthcare and hospital workforce
In the EU, it is estimated that almost 9% of the working population, including health professionals, administrative workers and labourers, work in the health and
social sectors.
The financial constraints, also a consequence of the economic crisis, are leading in most European countries to a reduction in the resources available for healthcare professionals, reducing the possibilities of hiring new staff. At the same time, the number of healthcare professionals is expected to dramatically drop off from 1,000,000 workers by 2020 due to ageing, while several countries, especially in Central and Eastern Europe, are experiencing migrations of their healthcare workforce. The Joint Action on Health Workforce Planning & Forecasting, funded by the Health Programme of the European Union, is in charge of creating a platform for collaboration and exchange of best practices. The goal is giving to the MSs the support they need in order to face the challenges that the expected shortage will produce and to prepare the future of the Healthcare Workforce.
These trends are likely to have major impacts on the hospital sector, as inpatient care alone absorbs about a third of the healthcare resources, and hospital sector gives work to half of active physicians. The European countries, European Organisations and EU institutions are discussing the possible impacts and achievable solutions to these issues. Interestingly, several countries are shifting competencies from doctors to nurses, creating new educational pathways and bachelor degrees addressed to nurses. In many cases, nurses and General Practitioners acquire new skills and competences, relieving the burden of hospital care by enforcing primary care institutions and community services.
An overview of the composition of the European healthcare workforce in 2011 highlights the presence of about 1,650,000 doctors and 3,770,000 nurses, with an average rate of about 2.3 nurses per doctor (Chart 13).
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In 2011, EU15 had around 369 physicians and 858 nurses per 100,000 inhabitants and EU13 had 275 physicians and 618 nurses per 100,000 inhabitants. Almost all the EU13 Member States had a share of physicians lower than the EU average, with the only exceptions being Bulgaria (386), Lithuania (385) and the Czech Republic (364) and a share of nurses lower than the EU average, with the only exceptions being the Czech Republic and Slovenia, whose values equalled the average. Between 2000 and 2011, the number of physicians per 100,000 inhabitants increased by 24.4% in EU15 and by 5.1% in EU13.
These figures seem generally to provide evidence of the policies implemented, or at least the trends for the management of healthcare professionals, especially concerning the allocation of resources and responsibilities between doctors and nurses. In the EU, the average rate of nurses per doctor is about 2.3. The highest values are in Ireland (4.6), Switzerland (4.4), Luxembourg (4.2), Slovenia (3.4) and the UK (3.2). In these countries, there is a high shift of competencies from doctors to nurses. Conversely, countries where the values are lower are: Bulgaria (1.2), Spain (1.4), Portugal (1.6), Italy (1.6), Austria (1.6) and Latvia (1.6).
In 2011, doctors working in hospitals were between 50% and 60% of the total, with the highest rates registered in France (81.8%) and Switzerland (70.8%) (Chart 14). Even if complete data for nurses are not available for many countries, figures suggest that, in 2010, the percentage of nurses working in hospital was, on average, 60%, this value being ranging between 39.7% in Ireland and 100% in Austria (Chart 15).
Relevant variations did not happen between 2000 and 2011, with the exception of Greece, which registered a significant reduction in the number of physicians working in hospitals (-10.0 p.p.) and in Lithuania, which had a considerable increase (+12.9 p.p.).
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In 2011, about 11 physicians and 36 nurses graduated for every 100,000 inhabitants. However, the values across countries were quite different. The number of physicians graduated per 100,000 inhabitants ranged from 6.2 in France to 20.0 in Austria.The number of nurses graduated per 100,000 inhabitants ranged from 3.9 in Bulgaria to 81.8 in Slovenia.
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Compared to 2000, the average number of physicians graduated in the EU per 100,000 inhabitants increased by 15.2%, while the number of nurses graduated per 100,000 inhabitants increased by 30.8%, with a rate particularly high in EU13, where this figure almost doubled (Charts 16 and 17). The increase in the number of physicians graduated per 100,000 was very high in Denmark, Portugal and Latvia (average of 140%). The number of nurses graduated grew especially in Poland, Latvia and Italy. These rates mirror the introduction and extension of the university-level education for nurses.
