The figures in the present document provide the most updated comparative picture of the situation of healthcare and hospitals
For a number of years, hospitals have been required to act more efficiently and to increase productivity, and increased performance is indeed apparent. Yet, healthcare systems are facing conflicting trends: short and long-term impacts of financial and economic restrictions; increasing demand of an ever-expanding and ageing population, which leads to more chronic patients; increasing request and availability of technological innovations; new roles, new skills and new responsibilities for the health workforce; and, more recently, the impact of the Covid-19 crisis.
To adapt to this situation, the role of hospitals is evolving further. 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 this document provide the most updated comparative picture of the situation of healthcare and hospitals, compared with the situation in 2006, just before the previous financial and economic crisis. They aim to increase awareness on what has changed in hospital capacity and, more generally, in secondary care provision within EU member states, generating questions, stimulating debate, and thereby fostering information exchange and knowledge sharing.
The main source of data and figures is the OECD Health Statistics (last update July 2020). Data on health expenditure as a percentage of total general government expenditure and on hospital beds in public- or privately-owned hospitals have been extracted from the Eurostat Database on Economy and Finance (last update May 2020) and on Health (last update February 2020), respectively. All EU member states belonging to OECD are considered, plus Switzerland, United Kingdom (UK) and Serbia (as HOPE has members in those countries), when data are available. In the text, these are reported as EU. Whenever considered appropriate and/or possible, 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, Czech Republic, Croatia, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia and Slovenia). When averages are reported, they are the results of our own calculations. The considered trends normally refer to the years 2006–2016. When data on 2016 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 for healthcare
The current health expenditure per capita is diverse in Europe. In EU15, the total current health expenditure in purchasing power parity in dollars per capita (PPP$) in 2017 ranged from 2238 PPP$ in Greece and 6010 PPP$ in Germany, whereas in EU13, this ranged from 1679 PPP$ in Latvia to 2853 PPP$ in Slovenia. In Switzerland, this reached 7037 PPP$ (Chart1).
Compared with 2006, the total health expenditure per capita in 2016 varied positively in all the countries taken into consideration in this analysis except in Greece where there was a decrease of -12%. Major increases have been registered in EU13: Estonia (+110%), Lithuania (+107%) and Poland (+103%). Smaller increases were registered in Spain (+36%), Italy (+25%) and Portugal (+24%), all belonging to EU15.
The total current health expenditure has increased on average of 50% in the EU in the last ten years.
Current public health expenditure includes all schemes aimed at ensuring access to basic health care for the whole society, a large part of it, or at least some vulnerable groups. Included are government schemes, compulsory contributory health insurance schemes, and compulsory medical savings accounts. Current private health expenditure includes voluntary health care payments schemes and household out-of-pocket payments. The first component includes all domestic pre-paid health care financing schemes under which the access to health services is at the discretion of private individuals. The second component corresponds to direct payments for health care goods and services from the household primary income or savings: the payment is made by the user at the time of the purchase of goods or use of the service.1
In 2017, the percentage of public sector health expenditure to the total current health expenditure exceeded 70% in most countries, except for Latvia (57%), Greece (60%), Portugal (61%), Hungary (69%), Lithuania (66%) and Poland (69%) and, outside the EU, in Switzerland (66%) (Chart 1).
In recent years, health expenditure of the public sector has accounted on average for 74% of total health expenditure and 24% of the total government expenditure.
Between 2006 and 2016, the public health expenditure in PPP$ per capita increased on average by almost +50%. The countries that registered the most significant increases were Lithuania (+105%), Poland (+105%) and Estonia (+117%), whereas those that registered minor increases were Luxembourg (+15%), Portugal (+19%) and Italy (+20%). Greece was the only country where this indicator decreased (-15%).
Chart 2 shows the last ten-year trend concerning the share of government expenditure in health. It presents the aggregated data concerning the EU, and the figures of the three countries having the highest and the lowest values in the year 2017, Switzerland and UK included.
In 2017, the percentage of government expenditure devoted to health in total health expenditure ranged from 7% in Cyprus to 20% in Ireland.
The trends illustrated in Chart 2 are generally positive between 2007 and 2017 with an average yearly increase of percentage of government outlays devoted to health by 0.08 p.p. Yet, from 2009 to 2010, this way of development slackened in many countries, the reasons being the effects of the financial crisis or the shift of interest and priorities to other sectors.
Out-of-pocket payments show the direct burden of medical costs that households bear at the time of service use. Out-of-pocket payments play an important role in every health care system.
In 2017, the private contribution to healthcare spending was around 24% in the EU, ranging from 17% in France to 35% in Latvia. Lowest values were registered in Luxembourg (16%), Germany (15%), the Netherlands (18%) and Sweden (15%), whereas highest values were registered in Latvia (43%), Hungary (31%) and Greece (40%). It is worth noting that Latvia, Hungary and Greece are at the same time among the countries with the lower current health expenditure on health in PPP$ that year (Chart 1).
Chart 3 illustrates the trend between 2006 and 2016 of both the total current health expenditure per capita and the private households’ out-of-pocket payments on health. These values present a correlation (R2 = 0.6147) showing that there is dependence between the two indicators. The chart highlights the fast growth of both expenses in the countries shown in the upper right part of the graph corresponding to countries belonging to EU13. In those at the lowest-left part of the graph, the out-of-pocket payments grew more slowly compared with total current health expenditure.
Between 2007 and 2017 the household out-of-pocket payments in PPP$ per capita has increased in all the EU countries, except for Greece (-5%) and Slovakia (-12%) (Chart 3). The most relevant increases in EU15 have been registered in The Netherlands (+81%). In Switzerland, the indicator variated in the years taken into consideration of +48% and the UK had an increase of +47%. In EU13, according to available data, highest increases were registered in Latvia (+76%), Czech Republic (+89%) and Lithuania (+122%) (Chart 3). The total household out-of- pocket payments in PPP$ per capita continued to increase, as the demand of healthcare services and, in turn, the total health expenditure did.
In the majority of the EU member states, 30%–40% of current health expenditure (excluding investments and capital outlays) finances hospital care. The funds allocated to providers of long-term care, ancilliary services, ambulatory care, preventive care as well as to retailers and other providers of medical goods are excluded from this computation.
In 2016, current hospital expenditure represented about 38% of total current health expenditure, ranging respectively from 29% and 32% in Germany and Latvia, to 46% and 47% in Italy and Estonia (Chart 4). 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 financed publicly (Chart 4). The total expenditure on in-patient care (PPP$ per capita) in the EU follows, on average, a growing positive trend. The exception is in Greece, where data available show that this indicator varies negatively (-19%).
Pharmaceutical expenditure covers prescribed medicines, over-the-counter and other medical non-durable goods. One of the indicators taken into consideration for 2016 is the expenditure on pharmaceuticals and other medical non-durable goods, as a percentage of current health expenditure. The countries that registered the lowest rates for this indicator are Denmark (7%), The Netherlands (8%), Luxembourg (9%) and Sweden (10%), whereas the highest rates were registered in Greece (26%), Lithuania (27%), Latvia (28%) and Hungary (29%).
Between 2006 and 2016, the percentage of pharmaceutical expenditure on total current health expenditure has generally declined in all Europe. In 2016, the total pharmaceutical expenditure was encompassed between 335 PPP$ and 369 PPP$ per capita in Denmark and Poland respectively, and 777 PPP$ and 1080 PPP$ per capita in Germany and Switzerland, respectively. At least half of it was held by the public sector in all countries except Denmark (44%), Latvia (35%) and Poland (34%) and Lithuania (33%). The highest values in 2016 were in Germany (84%), Luxembourg (80%), Ireland (77%), France (76%) and Slovakia (71%). In 2016, the pharmaceutical expenditure in PPP$ per capita held by the public sector was encompassed between 124 in Poland and 655 in Germany.
Chart 5 explores the relationship between the trend of the total and the public pharmaceutical expenditure between 2006 and 2016. In a group of outlier countries (upper right section of the chart) encompassing Estonia, Latvia and Lithuania, both the public and the total spending variates substantially. In Portugal, Luxembourg and Greece, the same indicators variated negatively.
From 2006 and 2016 in the EU, the total pharmaceutical expenditure decreased more than the public pharmaceutical expenditure, which decreased as well but at a slower pace. 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 15 years, healthcare reforms or other initiatives 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 decreased in most countries while the number of hospital beds decreased on average. These reforms/initiatives 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 those years, almost all European countries made changes in their hospital provision patterns; major efforts were addressed 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 future in completely overcoming the hospital-centric model of care.
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 – by prospective payment).
In most European countries, these policies led to changes in the management of patients within hospitals and offered a possibility to reduce 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 the 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.
Between 2006 and 2016 the number of hospitals decreased in most of the countries, while the number of hospital beds decreased by approximately 9%.
In 2016, there were on average 2.7 hospitals for 100,000 inhabitants, ranging from 1.4 in Slovenia to 4.8 in Finland. Moreover, there were on average 484 hospital beds for 100,000 inhabitants, ranging from 234 in Sweden to 806 in Germany.
Between 2006 and 2016, minor changes in the number of hospitals were registered in Luxembourg (-2), Slovenia (0) and the Czech Republic (+3) (chart 6). Major increases were registered in the UK (+175), France (+182), Poland (+229) and The Netherlands (+350). Major decreases were registered in Germany (-259), Italy (-193) and Ireland (-92).
In the same period, the total number of hospital beds decreased by 12% ranging from -43% in Finland (which means 302 beds cut for every 100,000 inhabitants) and -3% in Germany (which means 24 beds cut for every 100,000 inhabitants) (Chart 8). A positive variation was only registered in Poland (+3%) (Chart 8).
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 or for-profit private institutions (Chart 8). In 2016, in most of the countries where the data is available, the beds in private owned hospitals as percentage of all beds ranged from 1% in Slovenia and Lithuania to 38% in France (chart 9). The figure reached higher values in Cyprus (46%), Germany (59%) and The Netherlands (100%) (Chart 9).
In all the European countries, acute care hospital beds represent at least half of the total number of hospital beds.
The rate of acute care hospital beds for 100,000 inhabitants in 2016 in EU ranged from 215 in Sweden to 606 in Germany. The highest figures were observable in Belgium (512), Austria (555) and Lithuania (559) while the lowest figures in Spain (247), Denmark (251) and Italy (262) (Chart 10).
Between 2006 and 2016, the number of acute care hospital beds per 100,000 populations registered an average reduction by 13% in EU. The most significant decreases were in Latvia (-36%), Denmark (-32%) and Hungary (-28%). The only exceptions were Ireland (+3%) and Poland (+6%) (Chart 10).
The reduction in the number of hospital beds relates especially to public providers. In the countries where data are available, this trend can be associated or not with an increase of hospital beds in private organisations. It increased in Austria, Bulgaria, Croatia, Czech Republic, Germany, Latvia, Lithuania, Poland, Portugal and Romania. The countries that registered a decrease in both categories are Cyprus, Denmark, Estonia, Finland, France, Greece, Hungary, Italy, Malta, Slovenia and Spain.
The number of acute care discharges involves the entire pathway of hospitalisation of a patient, who normally stays in hospital for at least one night and then is discharged, returns home, is transferred to another facility or dies. Curative care comprises health care contacts during which the principal intent is to relieve symptoms of illness or injury, to reduce the severity of an illness or injury, or to protect against exacerbation and/or complication of an illness or injury that could threaten life or normal function. Curative care includes all components of curative care of illness (including both physical and mental/psychiatric illnesses) or treatment of injury; diagnostic, therapeutic and surgical procedures and obstetric services. It excludes rehabilitative care, long-term care and palliative care.
In 2016, the rates of acute care hospital discharges in European countries were quite dissimilar, ranging from 10% in the Netherlands and Italy and 24% in Austria and Denmark.
The average length of stay measures the total number of occupied hospital bed-days, divided by the total number of discharges. In 2016, the average length of stay in acute care hospitals ranged from five bed-days in The Netherlands and Greece to eight bed-days in Germany and Luxembourg.
Between 2006 and 2016, the number of inpatient discharges in acute care hospitals remained on average stable. However, the indicator varied consistently across the EU member states. Major decreases were registered in Latvia (-36%), Hungary (-25%) and Italy (-23%), whereas major increases were seen in Germany (+17%), Poland (+20%) and Switzerland (+25%).
Data suggest that about 16% of the population of the EU is admitted to hospital every year and that their average length of stay is around six days.
The link between the rate of admissions 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 might increase the risk of re-admissions with a consequent waste of resources both for the hospital and for the patients and their carers. At the same time, staying too long in a hospital might indicate inappropriate settlements of patients, also leading to a waste of resources.
Chart 11 compares the rate of hospital discharges and the average length of stay in for acute care hospitals in 2016. The last updated data shows that the average European figures correspond to a mean rate of discharges by 16% and a mean length of stay of six days for acute care hospitals. Chart 11 shows that both indicators are higher than the EU average in Slovenia, Poland, Slovakia, Lithuania and Germany.
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 2016, the average acute care occupancy rate in Europe was equal to 75%, but the gap between the highest and the lowest rate was 35 percentage points (p.p.).
Between 2006 and 2016, the average rate of acute bed occupancy decreased in Europe (Chart 12). The reduction was between -8.4 p.p. and -8.2 p.p. in the Czech Republic and The Netherlands, respectively, and -0.5 in Estonia and Italy. The increase was between +0.8 p.p. and +2.8 p.p. in the UK and Germany, respectively. In Ireland, the increase was 7.5 p.p (Chart 12). 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.
Hospital and healthcare workforce
According to the European Commission supplement to the quarterly review on Health and social services from an employment and economic perspective (December 2014), there is a large imbalance in skill levels 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, reducing the possibilities of hiring new staff. Additionally, several countries, especially in central and Eastern Europe, are experiencing migrations of their healthcare workforce.
European countries, European organisations and EU institutions are discussing 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 for nurses. In many cases, nurses and general practitioners acquire new skills and competencies thereby relieving the burden of hospital care by enforcing primary care institutions and community services.
The trends described above are likely to have major impacts on the hospital sector, as inpatient care alone absorbs about a third of the healthcare resources and since the hospital sector gives work to more than half of active physicians.
An overview of the composition of the European healthcare workforce in 2016 highlights the presence of about 1,400,000 physicians and 3,300,000 nurses with an average rate of about 2.4 nurses per physician (Chart 13).
In 2016, the share of practising nurses per 100,000 registered the lowest values in Greece (325), Poland (516), Spain (551) and Italy (557) (Chart 15). The highest values were in Germany (1285), Finland (1426), Denmark (1690) and Switzerland (1702). In the same year, the lowest share of practising physicians was registered in Poland (242), the UK (278), Luxembourg (288), Ireland (294) and Slovenia (301), whereas the highest values were in Germany (419), Switzerland (425), Sweden (427), Lithuania (447) and Austria (513) (Chart 14). Between 2000 and 2015, the number of both practising nurses and physicians increased by 15% in the EU, according to information available.
These figures provide evidence of the policies implemented, or at least of the trends for the management of healthcare professionals, especially concerning the allocation of resources and responsibilities between physicians and nurses. In the EU, the average rate of nurses per physicians is about 2.4 points. In 2016, the highest values were seen in Denmark (4.6), Luxembourg (4.1), Switzerland (4.0) and Belgium (3.6). In these countries, there is a high shift of competencies from physicians to nurses. Conversely, in countries where the values are lowest – such as Lithuania (1.7), Austria (1.6), Latvia (1.4), Spain (1.4) and Italy (1.4) – physicians continue to perform most of the clinical activities (Chart 13).
In 2016, according to data available, physicians working in hospital (full or part time) were around 50%–60% of the total, with the highest rates registered in Lithuania (66%), Estonia (68%), Switzerland (74%) and France (83%). By contrast, the lowest values were in Belgium (24%), the Netherlands (39%), Poland (45%) and Finland (46%) (Chart 14).
The most relevant positive variations on the number of physicians per 100,000 working in hospital between 2006 and 2016, have been registered in Switzerland (+49%), Germany (+34%) and Hungary (+32%). By contrast, this indicator registered negative variations in Poland (-2%) and Greece (-9%) (Chart 14).
In 2016, the average number of physicians and nurses graduated for every 100,000 inhabitants were respectively about 14 and 42 in the EU (Charts 16 and 17). However, the values across countries were quite different. The number of medical graduates per 100,000 inhabitants ranged from 9 in France and Greece to 24 and 22 in Ireland and Denmark, respectively (Chart 16). The number of nurses graduated per 100,000 inhabitants ranged from 15 and 16 in Luxembourg and the Czech Republic to 99 and 104 in Switzerland and Denmark (Chart 17).
Compared with 2006, the number of medical graduates per 100,000 inhabitants in the EU registered an overall positive variation. The countries that registered the highest increases were Portugal (+109%), Belgium (+137%), Slovenia (+156%) and Latvia (+158%). Minor positive variations concerned Germany (+11%), Sweden (+11%), Denmark (+12%) and Estonia (+13%). Decreases happened in Greece (-37%) and Austria (-16%) (Chart 16). The number of nurses graduated per 100,000 inhabitants registered different trends across the EU. Major positive variations were registered in Belgium (+75%) and Switzerland (+63%), whereas minor positive variations were registered in Latvia (+3%) and Hungary (+5%) (Chart 17). Negative variations ranged from -1% and -4% respectively in Poland and Austria, to -24% and -25% in Slovakia and Portugal (Chart 17). The most relevant decrease was registered in the Czech Republic (-68%) in the same years.
Pascal Garel HOPE Chief Executive
Lucia Gonzalez HOPE Comparison Officer