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Data from the Health for All Database provides the most up‑to‑date picture of the status of European hospital healthcare
HOPE, the European Hospital and
For several years, hospitals have been required to act more efficiently and to increase productivity. Increased performance is indeed possible. Yet today healthcare systems are facing conflicting trends: short- and long-term impact of an economic and financial crisis; increasing demand of an ever-expanding and ageing population; increasing request and availability of technological innovations.
To adapt to this situation, the role of hospitals is further evolving. Most health systems have already moved from a traditional hospital-centric and doctor-centric pattern of care to integrated models in which hospitals work closely with primary care, community care and home care.
The figures given in the present document provide the most updated comparative picture of the situation of healthcare and hospitals, compared to the situation at the beginning of the 21st Century. They aim to increase awareness of what has changed in hospital capacity and more generally in secondary care provision within European Union Member States, generating questions, stimulating debate and in this way fostering information exchange and knowledge sharing.
The source of data and figures are the Health for All Database from the World Health Organization (WHO/Europe, European HFA-DB, April 2014) and the European database on human and technical resources for health (WHO/Europe, HlthRes-DB, September 2014). All European Union Member States are considered, plus Switzerland and the Republic of Serbia (as both countries are 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, Netherlands, Portugal, Spain, Sweden and the UK) and EU13, for the countries that joined the EU after 2004 (Bulgaria, Cyprus, the Czech Republic, Croatia, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia and Slovenia). The considered trends normally refer to the years 2000–2012. When data from 2012 are not available, or they have not been gathered for a sufficient number of countries, the closest year is considered. Some figures are disputed for not being precise enough but at least they give a good indication of the diversity.
Financial resources in healthcare
From 2000 to 2012, the total health expenditure expressed in purchasing power parity (PPP$) per capita increased on average by 83% in the EU, with effects on inpatient care, out-of-pocket payments and pharmaceutical expenditure. These three figures are characterised by a growing and positive trend in the considered years.
The amount of total health expenditure per capita in 2012 was 3,346 PPP$ in the EU, with wide variations around this average value: 3,852 PPP$ in EU15 and 1,463 PPP$ in EU13.
Compared to 2000, the total health expenditure per capita in 2012 has increased in all European countries. In most of them it has more than doubled, but major increases can be highlighted in Serbia (+299%), Romania (+252%), Slovakia (+227%) and Bulgaria (+206%), where it has tripled or more.
Public sector 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 of multiple sources, including external funds.
In 2012, the percentage of public sector health expenditure of the total health expenditure was higher than 64% in most countries, with the exception of Cyprus, Bulgaria, Latvia, Portugal and Hungary and outside the EU, the Republic of Serbia and Switzerland.
Between 2000 and 2012, the public health expenditure more than doubled in many EU13 countries such as Cyprus, Poland, Slovakia, the three Baltic countries, Bulgaria and Romania and also in Finland, Spain and The Netherlands, belonging to EU15. While on average, the public health expenditure increase was 67% from 2000 to 2008, it was only 10% from 2008 to 2012 for the EU. This difference is of course due to the financial and economic crisis.
The chart below shows the last 12 years’ trends concerning the share of government expenditure on health. It presents the aggregated data concerning the EU, EU15 and EU13 and the figures of the three countries having the higher and the lower values in the year 2012, Switzerland included.
In 2012, the percentages of government expenditure devoted to health differed by five percentage points (p.p.) between EU15 (16.07%) and EU13 (11.83%); Switzerland shows a percentage close to 20.62%, which is higher but also growing faster compared to the EU Member States.
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 p.p. per year. Yet, from 2006 onwards, this way of development tapered off in many countries. The percentage of government outlays devoted to health increased on average by 0.04 p.p. per year. The reasons can be found in the economic difficulties starting or in the shift of interest and priorities to other sectors.
In 2012 the private households’ out-of-pocket payment in the EU accounted for 16.3% 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 2012, the private contribution to healthcare spending was around 14% in EU15 and 24% in EU13. It was higher than 30% in Portugal, Malta, Serbia, Latvia, Bulgaria and Cyprus and lower than 10% only in The Netherlands, France and the UK.
Between 2000 and 2012 the percentage of private households’ out-of-pocket payment to total health expenditure has steadily declined in the majority of European countries. It decreased by one p.p. in the EU, 0.9 p.p. in EU15 and by 0.8 p.p. and in EU13. The most relevant rates of reduction were registered in Poland (from 30% to 23%), Latvia (from 44% to 37%), Cyprus (from 56% to 49%), Switzerland (from 33% to 28%), Italy (from 25% to 20%) and Greece (from 34% to 30%). Nonetheless, the total out-of-pocket payments in PPP$ per capita continued to increase, as the total health expenditure did.
Chart 3 illustrates the trend in 2000–2012 of both the total per capita health expenditure and the private households’ out-of-pocket payments on health. These values present a correlation (R²=0.6463) showing that there is dependence between the two indicators.
The chart highlights the fast growth of both expenses in most countries of EU13 (graphically this phenomenon corresponds to the fact that these countries are located in the upper-right part of the graph) and a low increase of out-of pocket payment in some countries despite an average increase in total health spending of about 76% in EU15.
A third of health payments finances running expenses (excluding investments and capital outlays) of inpatient institutions for acute, chronic and convalescent care. The funds allocated to outpatient institutions or outpatient hospitals are excluded from this computation because they are included in the 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 34.1% of overall healthcare spending, ranging respectively from 19.8% and 21.0% in Portugal and Slovakia, to 45.2% in Switzerland, 46.1% in Italy and 46.4% in 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.
The last data available on expenditure on inpatient care PPP$ per capita refers to year 2011 and is available for 68% of EU countries, Switzerland included. For those countries, the total expenditure on inpatient care (PPP$ per capita) follows, on average, a growing positive trend. The exception is represented by Greece where from 2000 to 2011 this indicator varies negatively (–20%). In Italy, in the same period, the expenditure on inpatient care, PPP$ per capita was stable.
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 2012 about 18.6% of the European health expenditure went to pharmaceuticals. The highest rates were registered in Hungary (33.4%), Serbia (31.3%), Greece (28.5%) and Malta (28.3%); the lowest rates were in Denmark (6.8%), The Netherlands (9.4%), Switzerland (9.4%), the UK (11.4%) and Austria (11.7%).
Between 2000 and 2012 the percentage of pharmaceutical expenditure as a percentage of total health expenditure has generally declined in all of Europe. In 2012, the total pharmaceutical expenditure was encompassed between 280 PPP$ per capita in Estonia and 673 PPP$ per capita in Greece. At least half of it was held by the public sector in all countries except Denmark and Hungary (49.2%), Estonia (49.0%), Italy (45.5%), Serbia (44.7%), Malta (41.2%), Poland (39.4%), Latvia (38.4%) and Lithuania (34.2%). The highest values in 2011 were The Netherlands (78.4%) and Ireland (78.0%) while in 2012 were in the UK (84.7%) and Luxembourg (84.0%).
In 2012, the public pharmaceutical expenditure was encompassed between 129 PPP$ per capita in Poland and 505 PPP$ per capita in Ireland.
Chart 5 explores the relationship between the trend of the total and the public pharmaceutical expenditure between 2000 and 2012. In this period of time the average increase in the total pharmaceutical expenditure was 70%; the average increase in public pharmaceutical expenditure was 76%. In a group of outlier countries including Ireland, Greece, Estonia and Slovakia both the public and the total spending more than doubled. Only in Italy, Belgium, Slovenia, Luxembourg and Denmark were the rates of growth of total spending lower than 40%. In Italy, Slovenia and Sweden, the rate of growth of public outlays was lower than 30%.
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 2012. In almost all the Member States, the total pharmaceutical expenditure decreased more slowly than 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 last 12 years healthcare reforms 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 dropped off. But these reforms also resulted in a broad reduction of acute care admissions and length of stay, as well as improvements in the occupancy rate of acute care beds.
During these years almost all European countries made changes in their hospital provision patterns, major efforts were made to delivering better services, increasing quality, 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 result in the complete overcoming of the hospital-centric model of care in the future.
This was possible thanks to a package of financial and organisational measures addressed to improve coordination and integration between the different levels of care, increase the use of day-hospital and day-surgery and introduce 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, with prospective payment).
In more or less all European countries these policies 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 from the specific organisation of local, social and healthcare systems, that is, 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.
In 2012, there were on average 2.8 hospitals for 100,000 inhabitants, ranging from 1.4 in Slovenia to 4.9 in Finland. The only European Member State excluded from this range is Cyprus, where the value is around 9.8.
Moreover, there were on average 530 hospital beds every 100,000 inhabitants, ranging from 262 in Sweden to 818 in Germany.
Between 2000 and 2012 little changes in the number of hospitals were registered in Slovakia (–3), Luxembourg (–1), Malta (–1), Hungary (+1), Serbia (+2) 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 17.5%. The only countertrend was registered in Greece, whose hospital beds per 100,000 inhabitants increased by 2.8%, which means 13 new beds per 100,000 inhabitants.
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% only in Germany, Cyprus, France, Italy and Spain.
Between 2000 and 2011 the number of acute hospitals decreased significantly all over Europe. A total of 296 acute care hospitals were closed in France, 267 in Germany, 125 in Italy and 110 in Switzerland.
The rate of acute care hospital beds per 100,000 inhabitants in 2012 in Europe was 358. The highest figures were observable in Austria (547), Lithuania (538), Germany (528) and Bulgaria (511); the lowest figures were in Sweden (195), Ireland (209); Spain (230) and the UK (234).
Between 2000 and 2012, the number of acute care hospital beds per 100,000 populations registered an average reduction by 19% in the EU, 19% in the EU15 and 21% in the EU13. The most significant decreases were in Latvia (–41%), Estonia (–34%), Italy (–33%), Malta (–32%) and Hungary (–31%). The only exceptions were Greece and The Netherlands whose value increased by 8% and 9%, respectively.
The most relevant bed reductions, according to the last available data corresponding to the year 2007, happened in the surgical and in the medical groups of specialties, which together represent far more than half of acute care beds. The reduction in the surgical specialties was around 9%, the reduction in the medical specialties was around 11%, however it was particularly high, 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 then is discharged, returning home, being transferred to another facility or dying. The last data available for this figure refers to 2011. The rates of acute care hospital admissions in the European countries were quite dissimilar, ranging from 9.0% in Cyprus to 25.9% 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 ranged from 5.1 bed days in France to 7.9 bed days in Germany.
Between 2000 and 2011 almost all countries reduced their rate of admissions or at least stabilised it. Many of them were also able to reduce the length of stay in acute care hospitals; the EU average improved, decreasing from 7.6 bed days in 2000 to 6.4. bed days in 2011, the EU15 average improved by 1.1 bed days and the EU13 average improved by 1.3 bed days.
The link between the rate of admissions and the length of stay can be a very sensitive issue for hospitals, since it is commonly acknowledged that the length of stay being too short may increase the risk of re-admission with a consequent waste of resources both for the hospital and for the patients and their carers. At the same time, staying in a hospital for too long may indicate inappropriate settlements of patients, causing similar waste of resources as described above.
Chart 11 compares the rate of hospital admissions and the average length of stay in 2011. The average European figures indicate a mean rate of admissions of 17.3% and a mean length of stay of 9 days for all hospitals. The foremost variations between countries concern the admissions ranging from 9.0 in Cyprus to 27.5 in Austria. A cluster of countries mainly encompassing EU13, present a number of admissions per 100 equal to 19.2 and slightly higher than the EU average (17.3). 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 the hospital capacity is used.
In 2011, the average acute care occupancy rate in Europe was equal to 75.9%, but the gap between the highest and the lowest rate was 43 percentage points. Between 2000 and 2011 there were no consistent trends in Europe, the average rate of acute bed occupancy in EU decreased by one percentage point, the other values were encompassed between +9.5 p.p. and +7.4 p.p. respectively in Cyprus and Ireland 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 2013, the share of employment in the human health and social work sector on total employment in the 28 European Member States is in average 10.5%, according to the European Commission quarterly review on “Health and social services from an employment and economic perspective” (December, 2014). Furthermore, the health and social services sector, composed of human health, residential care and social work, has an important economic weight as it generates around 7% of the total economic output in the EU28 and appears to have suffered from the crisis. The review also underlines that the health and social services sector is facing several challenges due to the fact that the workforce is ageing faster than in other sectors. Also, there are large imbalances in skills level and working patterns, and recruitment and retention are conditioned by demanding working conditions.
The financial constraints are leading to a decrease in the resources available for healthcare professionals in most European countries, thus reducing the possibilities of hiring new staff. Additionally, several countries, especially in central and Eastern Europe, are experiencing migrations of their healthcare workforce.
These trends are likely to have a major impact on the hospital sector, since inpatient care alone absorbs about a third of the healthcare resources and hospital sector gives work to half of active physicians. The total hospital employment in 2012, per 100,000 inhabitants in EU28 was 1502 people in general and speciality hospitals. European countries, European organisations and EU institutions are discussing possible impacts and achievable solutions to these issues. Interestingly, several countries are shifting competences 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 1,640,000 doctors and 3,770,000 nurses, with an average rate of about 2.3 nurses per doctor.
In 2012, EU15 had around 351 practicing physicians and 922 practicing nurses per 100,000 inhabitants and EU13 had 277 physicians and 588 nurses per 100,000 inhabitants. Almost all the EU13 Member States had a share of practicing physicians lower than the EU average (334), with the only exceptions of Estonia (337), Czech Republic (368), Bulgaria (391) and Lithuania (422). The share of practicing nurses per 100,000 in EU is on average about 808. Almost all the countries are characterised by lower rates with the only exceptions of Luxembourg, Belgium, United Kingdom and Slovenia, whose values are 1192; 952; 832 and 817, respectively. Between 2000 and 2012, the number of physicians per 100,000 inhabitants increased by 15.8% in EU15 and by 9.7% in EU13.
Generally, these figures seem 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 EU the average rate of nurses per doctor is about 2.3 points. In 2011 the highest values are in Ireland (4.6), Switzerland (4.4) and Luxembourg (4.2). 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) and Spain (1.4). In Portugal, Italy, Austria and Latvia, the rate of nurses per doctor is equal to 1.6.
In 2012, doctors working in hospitals were around 50–60% of the total, with the highest rates registered in France (82.0%) and in Denmark (71.5%). On the other side, the lowest values regard Cyprus (25.6) and Belgium (25.8). Even if complete data for nurses are not available for many countries, figures suggest that in 2011 nurses working in hospital were on average 64%, this value being encompassed between 41.9% in Ireland and the totality of nurses in Austria and in Greece.
Relevant variations did not happen between 2000 and 2012, except in Portugal and in Greece that registered a significant reduction in the percentage of physicians working in hospitals (respectively –12.9 and –10.0 p.p.) and in Lithuania (+14.1 p.p.), Malta (+10.7 p.p.) and Hungary (+10.0 p.p.) that had a considerable increase.
In 2012, about 11.5 physicians and 35.4 nurses graduated every 100,000 inhabitants. However, the values across countries were quite different. The number of physicians graduated per 100,000 inhabitants ranged from 8.6 in Sweden to 19.7 in Austria. The number of nurses graduated per 100,000 inhabitants ranged from 3.9 in Bulgaria to 89.4 in Croatia.
Compared to 2000, the average number of physicians graduated in the EU per 100,000 inhabitants increased by 20.2%, while the number of nurses graduated per 100,000 inhabitants increased by 36.0%, with a rate particularly high in EU13 where this figure is 53.2% on average. In EU15 the increase rate is lower than in the EU and equal to 30.8%. The increase in the number of physicians graduated per 100,000 was very high in Latvia, Slovenia, Portugal, Estonia and Denmark (on average 142.4%). The number of nurses graduated grew especially in Poland, Italy, Latvia and Malta. These rates mirror the introduction and extension of the University level education for nurses.