Pascal Garel
Chief Executive
Gloria Lombardi
Health economist
Hospitals are subject to increasing pressure. Scientific innovations and technological advances open up many opportunities to improve quality of care and patient satisfaction, but the financial constraints, consequence of the economic crisis, and the increasing number of chronic patients add to the natural complexity hospital and healthcare services are facing. However, all over Europe many useful efforts are being made to improve the efficiency of hospital provision and improve the appropriateness of care. The reduction of acute hospital beds, acute inpatient care admissions and length of stay show that those efforts have been fruitful. Looking at the past, with an eye towards the future, data and indicators presented in this article give a picture of hospital situation compared to 10 years ago.
Data and figures have been taken from the Health For All Database of the World Health Organisation (WHO/Europe, European HFA Database, July 2010) unless otherwise specified. Data referring to the expected trends of population in the upcoming decades have been taken from “Europe in figures-EUROSTAT yearbook”. Usually, years 1998 and 2008 have been considered for comparison, however, with regard to hospital capacity indicators, consistent figures are available only for 2007. Some figures are disputed for not being precise enough but they at least give a good indication of the diversity.
All European Member States are considered, and, whenever appropriate, two groups have been compared: EU-15, the countries that joined the EU before 2004 (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and United Kingdom) and EU-12, the countries that joined the EU in 2004 and 2007 (Bulgaria, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia and Slovenia); moreover, data about Switzerland have also been added in this edition.
1. Demographic trends
From the sixties up to now the population number in Europe has steadily increased, growing at a faster pace during the 1960s, and slowing down after the 1970s. Between 1980 and 2008 the European inhabitants have risen by about 9%, but the increase between 2000 and 2008 has only been close to 3%. Conversely, during the next decades the number of European inhabitants is expected to increase rather slowly until 2035 (about +5% between 2008 and 2035), then to start falling until 2060. This trend will be strongly driven by the EU-12, whereas the population in most EU-15 is projected to continue expanding.
The most relevant aspect highlighted by the projections is the considerable shift in the age structure. The share of older persons in the total population is expected to increase significantly from 2010 onwards. The post-war baby-boom generation starts to reach retirement age, the life expectancy is still increasing and the birth rate sharply falls down. Persons aged 65 or over will account for 30% of the EU-27’s population by 2060, compared to a 17% share in 2008. The ratio of the number of working-age people to those aged over 65 will be reduced from four to one in 2008 to less than two to one by 2060.
Moreover, the rate of people aged 80 and over will shift in Europe from about 4.4% in 2008 to 8% in 2035 and 12.1% in 2060. Between 2008 and 2035, the highest rates of increase will be registered in most EU-12 Member States, such as Cyprus (+169%), Slovakia (+139%), Slovenia (+134%) and Czech Republic (+133%). Nevertheless the highest shares of inhabitants aged more than 80 years will be registered in some of the bigger European countries: Italy (9.1% in 2035 and 14.9% in 2060), Spain (11.3% in 2035 and 14.5% in 2060), Germany (8.9% in 2035 and 13.2% in 2060) and Greece (7.9% in 2035 and 13.5% in 2060).
These changes will have a strong impact on the future design of healthcare systems throughout Europe, since they will likely result in a considerable increase in the need for professional services, social care and healthcare provision.
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2. Financial resources
Between 1998 and 2008, the European countries have allocated to healthcare on average 8.5% of their Gross Domestic Product (8.0% in 1998, 9.0% in 2008). Some differences among countries can be highlighted. Austria, France, Germany and Switzerland have devoted to health at least 10% of their GDP. Conversely, in some countries, (Cyprus, Estonia, Latvia and Lithuania) less than 7% of GDP has been invested in the health system. In general, there were no relevant fluctuations in the share of healthcare expenditure as percentage of GDP. In that period, this value increased by more than 2% only in Ireland (from 6.2% to 8.7%), UK (from 6.7% to 9%), Portugal (from 8.0% to 10.1%), Slovakia (from 5.7% to 7.8%) and Bulgaria (from 5.2% to 7.3%).
The amount of total health expenditure per capita in 2008 was $2,877 in EU-27, with wide variations around this average value: $3,320 in EU-15, $1,195 in EU-12. Compared to the 10 previous years, in 2008 the total health expenditure per capita increased in all European countries. In most of them it more than doubled, but major increases can be highlighted in Bulgaria, Romania and Slovakia, where the per capita health expenditure tripled or nearly tripled, and in the case of the three Baltic countries, where the average increase was higher than 150%.
A major part of health expenditure is handed over to the public finance. It includes expenditure incurred by state, regional, local governments and social security schemes, encompassing publicly financed investment in health facilities and capital transfers to the private sector for hospital construction and equipment. In 2008 the share of public sector health expenditure was higher than 70% in all European countries, with five exceptions: Cyprus (45.1%), Bulgaria (57.8%), Latvia (59.6%), Switzerland (59.0%) and Greece (60.9%).
Between 1998 and 2008 the share of public spending on healthcare markedly rose in Romania (+18.9%), the Netherlands (+18%), Greece (+8.8%) and Ireland (+8.2%), whereas it sensibly declined in Slovakia (-24.8%), Bulgaria (-11.3%) and Estonia (-7.6%).
About one-third of total health expenditure supports the delivery of inpatient care. This means that one third of health payments go to the financing of running expenses, excluding investments and capital outlays, of inpatient institutions for acute, chronic and convalescent care. All funds allocated to outpatient institutions or outpatient hospital departments are excluded from this computation. They are covered under ambulatory care expenses. Nevertheless this separation is sometimes not statistically possible for some countries, hence a quote of overlap must always be assumed.
In 2008, expenditure on inpatient care represented on average 34.9% of overall healthcare spending, ranging from 19% and 21% respectively in Portugal and Slovakia, to 52% and 44% respectively in Latvia in Switzerland. Here, only those countries for which complete data are available are considered (see Chart 2), but the information provided is sufficient to remark the importance of the inpatient sector in the overall health system.
A common feature of all European countries is the massive predominance of public funding in inpatient care: 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.
Between 1998 and 2008, expenditure on inpatient care has not been growing as fast as the total health expenditure. On the contrary, in most European countries spending on inpatient care as a percentage of overall healthcare spending remained the same or decreased, as a result in several cases of policies aiming at controlling expenses, gain efficiency and increase productivity in hospitals.
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3. Hospital capacity and delivery of care
During the last decade almost all European Member States made changes in their hospital services. The number of hospital facilities, as well as of hospital beds dropped off. Major efforts were addressed to deliver a better service, increasing quality of care and safety of population and improving 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, overcoming almost everywhere the hospital-centric model of healthcare system. This was possible thanks to a package financial and organisational measures addressed to improve coordination between acute care, tertiary care and social care, foster integration between primary, hospital and ambulatory care, increase possibilities of day-hospital and day-surgery and introduce new and more efficient methodologies of hospital financing to incentivise appropriateness (e.g. the replacement of daily payments – known to encourage longer hospitalisation – by prospective payment).
In almost all European countries these policies led to changes in the hospital management of patients and opened the possibility of reducing the number of acute care hospital beds. They also resulted in a regular reduction of the acute care average length of stay and, in several countries, in improvements in the rate of acute care hospital admissions. Bed occupancy rates, on the other hand, registered more disparate trends across Europe, depending also from the demographic and epidemiological structure of population and from the specific organisation of local, social and healthcare systems, i.e. the structure of primary care, the presence and the efficiency of a gate-keeping system, the modality of access to secondary care, availability of home care and development of community care.
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3.1 Hospital provision
In 2008 in Europe there were on average 2.6 hospitals for 100,000 inhabitants, ranging from one in the Netherlands to almost six in Finland. Moreover, there were on average 530 hospital beds every 100,000 inhabitants, ranging between about 320 in Spain and little more than 800 in Germany.
Between 1998 and 2008, the average number of hospitals in Europe decreased by about 6%, with values encompassed between -1.7% in Spain (-13 hospitals) and -41.3% in Latvia (-62 hospitals). In the same period, the total number of hospital beds per 100,000 inhabitants decreased by about 18%, the only countertrend was registered in the Netherlands, where this value increased by about 31%.
In most of these countries, the decrease in the total number of beds was accompanied by an increase in the number of private inpatient hospital beds. However, in 2008 the share of private hospital beds was still quite low in most EU-12 Member States, while it reached values little higher than 30% in many EU-15 Member States.
Acute care hospitals represent at least half of the total number of hospitals in almost all European countries.
Between 1998 and 2008 their number decreased significantly all over Europe. Two hundred and seventy-four acute care hospitals were closed in Germany, 249 in France, 130 in Italy. In comparative values, their number almost halved in Latvia and Estonia and decreased by about one third in Hungary, Slovakia and Switzerland, better adapting to the actual needs of population.
Between 1998 and 2008, the number of acute care hospital beds per 100,000 populations in Europe registered an average reduction by 18%, highlighting a slightly faster decrease in the first five years (-10.9% between 1998 and 2003 and -8.1% between 2003 and 2008). The only exception was Greece, with an increase by 4% in the entire period.
The decrease was remarkable in all European countries. In EU-15 it ranged between -6.5% in Ireland and -40.2% in Italy, in EU-12 it was encompassed between -3.7% in Romania and -34.1% in Estonia.
However, in 2008 there was still a little more than 20% difference in the total number of acute care beds per 100,000 inhabitants between EU-15 (on average 360 beds) and EU-12 (on average 467 beds).
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3.2 Use and efficiency of hospital capacity in acute care hospitals
In the last 10 years the healthcare reforms implemented all over Europe, aiming at rationalising the use of secondary care and reducing the costs of hospitalisation, brought to a reduction in the number of hospital beds, and also resulted in a broad reduction of acute care admissions and length of stay, and in a quite, even if jeopardised, improvement of the rate of occupancy of acute care beds.
The number of acute care admissions involves the entire pathway of hospitalisation of a patient who normally stay in hospital for at least 24 hours and then is discharged, returning home, being transferred to another facility or dying.
In 2007, the rates of acute care hospital admissions in the European countries were quite dissimilar, ranging from 7.8% in Cyprus to 26.6% in Austria.
In comparison to the 10 years before, almost all countries reduced their rate of admissions or at least it remained on the same average. Between 1998 and 2007, the European average decreased by almost 2%, from 17.5% to 15.6%. The most remarkable rates of reduction were registered in France and Italy, respectively -4.3% and -3.7%. Conversely, Austria was the only country having a significant increase of its percentage of admissions, that, from the end of 1990s, steadily increased by 2.3%.
The average length of stay measures the total number of occupied hospital bed-days, divided by the total number of admissions or discharges.
In 2007 the average length of stay in acute care hospitals roughly ranged from five to eight bed days, with inferior values only in Denmark, Finland and Malta (from 3.5, 4.0, 4.3 bed-days).
Between 1998 and 2007, almost all European countries were able to reduce the length of stay by at least one bed-day; few exceptions were the smallest countries, Denmark, Malta and Luxemburg, whose variation were minors.
The average reduction was close to two bed days in EU-12. Some of the most relevant reductions happened in Estonia (-2.9 bed-days), Lithuania (-2.5 bed-days), Slovakia (-2.5 bed-days) and Slovenia (-2.4 bed-days).
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.
In 2007, the average acute care occupancy rate in Europe was equal to 77%, but the gap between the highest and the lowest rate was wider than 20%. The lowest values were registered in Belgium (66.6%) and in the Netherlands (68.1%). The better rates were in Ireland (87.2%), Switzerland (85.2%) and the UK (83.6%).
Between 1998 and 2007 there was not a clear trend across Europe. In some countries the rate of occupancy of acute care hospitals increased, for example in many EU-15 Member States, in other cases it dramatically decreased, like in Belgium (-13.3%), Slovakia (-9.6%) and Hungary (-7.6%).
These large variations among countries 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.
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4. Healthcare professionals
In the EU, it is estimated that almost 9% of the working population, including health professionals, administrative workers and labourers, are working in the health and social care sectors.
The financial constraints, consequence of the economic crisis, are leading in most 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 over the next decade due to ageing. At the same time several countries, especially in central and eastern Europe, are also experiencing migrations of their healthcare workforce. These trends are likely to have major impacts on the hospital sector, since inpatient care, alone, absorbs about one third of the healthcare resources and hospital sector gives work to half of active physicians.
The European Union, European Organizations and Member States are discussing the possible impacts and achievable solutions to these issues. Several countries are changing their patterns of care. They are for example shifting competencies from doctors to nurses, creating new educational pathways and bachelor degrees addressed to nurses. In many cases they are relieving the burden of hospital care by enforcing primary care institutions and community services.
4.1. Physicians and nurses
The profile of health professionals and the way they are managed differs a lot throughout Europe. The increasing diffusion of part-time working, progressive ageing of hospital staff, high rates of early retirements and decrease in the total number of new medical professionals are common characteristics and make comparison difficult. Moreover, the free movement of professionals within the European internal market sometimes creates distortions in the interpretation of actual workforce figures. A solution would be the use of Full Time Equivalents (FTE), which measure the real amount of work absorbed by an activity. Unfortunately the FTE method is still applied differently. Figures, such as the number of working hours per week may vary from country to country, data are often gathered and treated with different levels of accuracy and not always consistently available. This section will then compare the figures about healthcare professionals considering the crude number of physicians and nurses physical persons, normally compared to the countries’ population.
An overview of the composition of the healthcare workforce (physicians and nurses) in the European Union over the last decade shows the presence of about 1.4m doctors and 2.6m nurses, with a more or less stable rate of two nurses per each doctor in average.
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In 2008 in the European Union there were about three physicians and almost eight nurses every 1,000 inhabitants. In the same year graduated about 10 physicians and 30 nurses every 100,000 inhabitants. Unfortunately these figures do not fairly mirror the situation across countries. Comparing the values in EU-12 and EU-15 Member States a sharp difference in the total number of physicians and nurses can be observed.
Almost all EU-12 Member States had in 2008 a number of physicians per thousand inhabitants lower than the EU average (3.2). The only exceptions were Lithuania, Bulgaria, Czech Republic and Estonia, though with less than 3.7 doctors per 1,000 inhabitants. The same year, all EU-12 Member States had a number of nurses per thousand inhabitants of one to three points lower than the EU average (7.8), with the only exception of Czech Republic and Slovenia, which values equalled the averaged.
In the EU-15 figures seem to generally provide some evidence of the policies implemented for the management of healthcare professionals, especially concerning the allocation of resources and responsibilities between doctors and nurses.
Greece, Austria and Italy had in 2008 the highest rates of doctors per population and at the same time among the lower rates of nurses per populations. This data clearly represent the situation in countries having consolidated doctor-based systems. Conversely, countries where the shift of competencies from physicians to nurses is advanced, like Finland and Ireland (but also the UK should be mentioned here) registered in 2008 a rather low share of doctors per population, and the highest rates of nurses (15 nurses per 1,000 inhabitants).
The situation concerning the number of nurses and doctors graduated is much more complex and fragmented.
In 2008 the number of physicians graduated per 100,000 inhabitants in Europe was 10, encompassed between 7.2 in Poland and 15.2 in Ireland. The only exceptions were Latvia (4.5), where the number of physicians graduated had almost halved in ten years, and Austria (21.6), where this number had registered an increase since the beginning of 2000s.
The average number of nurses graduated per 100,000 inhabitants in Europe in 2008 was 29. All countries’ values (excluding Belgium and Cyprus, for which data are not available) were generally around the average, with some exceptions. In Bulgaria, a dramatic decrease lasted for ten years led to only 4.4 graduated nurses per 100,000 inhabitants in 2008. Instead, figures massively over the average characterised Slovakia (81.5), Denmark (78.6), Switzerland (81.5), Finland (56.1) and Sweden (49.9). In Slovakia, Switzerland and Sweden, this was the product of ten years steady increase. On the contrary, Finland registered a high value despite the continuous reduction happened between 1998 and 2008. Only in Den- mark these figures have always been even up to 60 points over the EU average.
The major increases in the number of graduated nurses between 1998 and 2008 happened in Italy, Portugal and Poland. In some cases this was due to the introduction of bachelor degrees and, in general, new career opportunities for nurses. Nonetheless, in none of these countries, trends in the number of nurses graduated could equal trends in the number of graduated doctors. Once more it puts some evidence on countries’ healthcare system organisation, testifying how the healthcare systems in these countries continue to be doctors-lead and the central element of the system is likely to be represented by the hospital inpatient care.
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The chart above compares the variation in the total number of physicians and the variation in the number of physician graduated per 100,000 inhabitants. The period considered is 2000–2008 for reason of simplicity and because data are more consistent. All countries are represented except Cyprus, Luxembourg, Malta, Romania and Switzerland, whose data are not available or incomplete. Countries of EU-15 are blue, countries of EU-12 are purple.
- Most countries are situated in the quadrant right aloft – increase both in the total number of physicians and in the number of physicians graduated – with some notably differences
- In Germany, Ireland, Sweden, the Netherlands, the UK and Greece the increase in the total number of doctors was higher than the increase in the number of doctors graduated
- Conversely, in Czech Republic, Slovenia, Austria, Denmark and Portugal, the increase in the number of doctors graduated was much higher than the increase in the total number of doctors; in particular in Denmark and Portugal the number of doctors increased by a little less than 20%, while the number of graduated more or less doubled
- In Italy, Lithuania and Hungary the variations in the total number of doctors were quite irrelevant, but the physicians graduated increased just by 3% in Italy, and by 17% and 24% in Lithuania and Hungary
- Poland is the only country to be localised in the quadrant left aloft – decrease in the total number of physicians and increase in the number of physicians graduated – with the first value a little higher than the second one
- Slovakia and Belgium are in the quadrant at the bottom left – decrease in both considered parameters – in both cases the decrease in the number of physicians graduated almost doubled the decrease in the total number of physicians
- Many countries are also localised in the quadrant at the bottom right – increase in the total number of physicians and decrease in the number of physicians graduated – and also here there are some notably differences
- Finland is the only country where the increase in the number of doctors counterbalanced the quite small decrease in the number of doctors graduated
- In Estonia, Bulgaria and Latvia the increase in the total number of doctors was really small, but the decrease in the number of doctors graduated was striking
- France and Spain were almost on the average, with very smaller variations in France than in Spain.
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4.2 Health professionals working in hospitals
Statistical comparison of hospital staff is often limited. On one hand, this is due to the frequent lack of consistently-used measurement tools; on the other, this is linked to the development of outsourcing of auxiliary services (maintenance, catering, etc.) whose staff is no longer directly employed by the hospital, and thus no longer counted as hospital staff.
In general, the most available and reliable data show that in the last decade the largest number of nurses and physicians in the European countries has been working in hospitals.
Complete data for nurses are available only in a few countries, and show a percentage of nurses working in hospitals not lower than 50% (Switzerland) and up to 100% (Austria and Greece) between 2006 and 2008.
In 2008, doctors working in hospitals were around 50 to 60% of the total number of physicians. Low rates were registered only in Belgium (15.6%), the Netherlands (38.6%) and Greece (38.6%). The highest rate was in Denmark (68.6%).
While relevant variation did not happen in any European country, between the late nineties and 2008 Greece registered a significant reduction of its physicians working in hospitals (-22.4%), while only Spain and Lithuania had a considerable increase (+15%).
