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Hospitals in Europe – data and trends

Pascal Garel 
Chief Executive 

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Gloria Lombardi 
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For several years, hospitals have been required to act more efficiently and to increase productivity, and indeed increased performance is visible. Yet, today healthcare systems are facing conflicting trends: increasing demand of an ever-expanding and ageing population; short- and long-term impacts of an economic and financial crisis, and increasing request/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 an integrated model of hospitals working closely with primary care, community care and home-care.
The figures given here provide the most up-to-date comparative picture of the situation of healthcare and hospitals, compared to the situation ten years ago. They aim to increase awareness of what has changed in hospital capacity and, more generally, secondary care provision within European Union Member States, generating  questions and 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 2011). All EU Member States plus Switzerland are considered. 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 United Kingdom) and EU12, for the countries that joined the EU in 2004 and 2007 (Bulgaria, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia and Slovenia). The considered trends normally refer to the decade 2000-2009. When data on 2009 are not available, or when 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, but even so they give a good indication of the diversity.
Financial reasources for  healthcare 
In the present economic and financial crisis, the impact of cuts did not lead to a reduction in health expenditures, but they did start growing at a slower pace, with effects on inpatient care, out-of-pocket payment and pharmaceutical expenditure. In some countries particularly affected by the global economic situation, the share of health spending in the GDP did in fact increase. 
The amount of total health expenditure per capita in 2008 was 2,877 PPP$ in EU27, with wide variations around this average value: 3,320 PPP$ in EU15, 1,195 PPP$ in EU12 (Chart 1). 
Compared to the ten previous years, in 2008 the total health expenditure per capita increased in all European countries. In most of them, it has more than doubled, but major increases can be highlighted in Bulgaria, Romania and Slovakia, where it has trebled or nearly trebled, and in the case of the three Baltic countries, where the average increase has been higher than 150%.
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 2008, the percentage of public sector health expenditure to the total health expenditure was higher than 70% in most countries, with the exception of Cyprus (45.1%), Bulgaria (57.8%), Latvia (59.6%), Switzerland (59.0%) and Greece (60.9%). 
Between 2000 and 2008, the public health expenditure more than doubled in Romania (+166.8%), Latvia (+155.0%), Estonia (+138.9%) and Ireland (+127.3%).
Chart 2 shows the past ten-year trend in the rate of government expenditure on health. It presents the aggregate data concerning the EU, EU15 and EU12 and the figures of the three countries having the higher and the lower values, plus Switzerland.
In 2008, the percentages of government expenditure devoted to health differed by 6 percentage points between EU15 and EU12, being lower in the last group of countries; Switzerland shows a percentage close to 20% – rather higher and in particular growing faster than in EU Member States. 
The chart also illustrates that trends were generally positive between 1999 and 2006 – with an average increase of percentage of government outlay devoted to health by 0.2% per year. Yet, from 2006 onwards, this rate of development slacked 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. 
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 2008, the private contribution to healthcare spending was 14.5% in EU15 and 23.4% in EU12. It was higher than 30% only in Cyprus (46.4%), Latvia (39.0%), Greece (37.0%) and Bulgaria (36.5%), lower than 10% only in Luxembourg (6.2%), The Netherlands (6.3%), France (6.8%) and Ireland (9.2%).
Between 2000 and 2008, the percentage of private households’ out-of-pocket payment to total health expenditure steadily declined in the majority of European countries. It lessened by 2.0 percentage points in EU, by 1.4 p.p. in EU15 and by 3.7 p.p. in EU12. The most relevant rates of reduction were registered in Romania (from 32.3% to 18.7%), Cyprus (from 55.9% to 46.4%) and Malta (from 26.7% to 20.1%). Nonetheless, the total out-of-pocket payments in PPP$ per capita continued to increase, as did the total health expenditure.
Indeed, in 2008, the private households’ out-of-pocket payment was 471.0 PPP$ per capita in Europe, registering values particularly high in Cyprus (1,536.8), Switzerland (1,423.0) and Greece (1,055.2). The lowest values were instead in Romania (124.4), Czech Republic (230.7), The Netherlands (236,2), Estonia (246.4) and France (256.9). The reasons behind these discrepancies can be mainly attributable to different types of social security systems. Nonetheless, the phenomenon of under-the-table outlays, still diffuse in some countries, cannot be ignored. 
In general, between 2000 and 2008, in EU the out-of pocket household spending increased by 38.4% (from 340.4 PPP$ to 471.0 PPP$) while the total health spending increased by 55.3% (from 1,853.25 PPP$ to 2,877.5 PPP$).
Chart 3 illustrates the trend 2000-2008 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 EU12 (red colour) and the very low increase of out-of pocket payment in Belgium, Italy, Malta and The Netherlands, compared to an increase in total health spending, which in these four countries is between 30% and 60%.
A third of health payments finance running expenses (excluding investments and capital outlays) of inpatient institutions for acute, chronic and convalescent care (Chart 4). All funds allocated to outpatient institutions or out patient hospital departments are excluded from this computation, because covered under ambulatory care expenses, nonetheless 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 35.0% of overall healthcare spending, ranging from 21.0% in Portugal and Slovakia, to 46.0% in Italy and Switzerland, 41.4% in Belgium and 40.0% in Austria.
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.
Between 2000 and 2008, expenditure on inpatient care did not grow as fast as the total health expenditure. On the contrary, in most countries spending on inpatient care as a percentage of overall healthcare spending either remained the same or decreased, as a result (in several cases) of policies aiming at controlling expenses, gaining efficiency and increasing productivity in hospitals.
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 2009, about 18.8% of the European health expenditure went on pharmaceuticals. The highest rates were registered in Hungary (32.6%), Lithuania (28.6%) and Slovakia (26.6%); the lowest rates were in Denmark (7.3%), Luxembourg (9.1%), The Netherlands (9.6%) and in Switzerland (10.1%).
Between 2000 and 2008, the percentage of pharmaceutical expenditure to total health expenditure generally declined in all of Europe, in particular in Slovakia (-7.4 p.p.), Poland (-6.0 p.p.), Czech Republic (-4.0 p.p.) and Italy (-4.2 p.p). The only increases were registered in Greece (+5.9 p.p.), Hungary (+4.1 p.p.) and Ireland (+3.4 p.p.). In 2008, the total pharmaceutical expenditure was between 312.9 PPP$ per capita in Poland and 661.0 PPP$ per capita in Ireland. More than half of it was held by the public sector in all countries except Latvia (26.5%), Poland (38.3%) and Estonia (42.9%). The highest values were 84.7% in the UK, 83.1% in The Netherlands and 79.0% in Greece.
The public pharmaceutical expenditure was between 109.4 PPP$ per capita in Poland and 534.6 PPP$ per capita in Greece.
Chart 5 explores the relationship between the growth of the total and the public pharmaceutical expenditure between 2000 and 2009. In this period of time, the average increase in the total pharmaceutical expenditure was between 40% and 70%; the average increase in public pharmaceutical expenditure was between 30% and 70%. In a group of outlier countries (Greece, Ireland, Estonia and Slovakia), both the public and the total spending more than doubled. Only in Belgium, Italy, Slovenia and Luxembourg were the rates of growth of total spending lower than 40%. In Belgium, Slovenia and Sweden, the rate of growth of public outlays was lower than 30%.
The chart highlights that, in all European countries, the total pharmaceutical expenditure has lately grown slightly faster than the public pharmaceutical expenditure. This suggests that a progressively larger part of this spending now 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 ten years, healthcare reforms implemented across Europe have been aimed at rationalising the use and provision of hospital care, improving its quality and appropriateness and reducing its costs. The number of hospital facilities has dropped off, as has the number of hospital beds. 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 this decade, almost all European countries made changes in their hospital provision patterns, with major efforts addressing the delivery of 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 (Chart 6 and Chart 7) and moved towards more integrated and efficient patterns of care, which might in the future result in the complete overhauling of the hospital-centric model of care.
This was possible thanks to a package of financial and organisational measures addressing the improvement of 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 so as to incentivise appropriateness (e.g. the replacement of daily payments – known to encourage longer hospitalisation – by prospective payment).
In more or less all European countries, these policies led to changes in the management of patients within hospitals and offered the possibility of reducing the number of acute care hospital beds. Only the bed occupancy rates registered more disparate trends across Europe, depending on the demographic and epidemiological structure of populations and on 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.
In 2009, there were on average 2.7 hospitals for 100,000 inhabitants, ranging from 1.1 in the Netherlands to 5.5 in Finland.
Moreover, there were on average 529 hospital beds for every 100,000 inhabitants, ranging from 276 in Sweden to 824 in Germany.
Between 2000 and 2009, little change in the number of hospitals was registered in Spain and Hungary, while 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 14.3% (Chart 8). The only counter trend was registered in Greece, whose hospital beds per 100,000 inhabitants increased by 2.8%, which means 13 new beds for every 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 (Chart 9). 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 Belgium, Cyprus, France, Germany, Greece, Italy, The Netherlands and Spain. 
Between 2000 and 2009, the number of acute hospitals decreased significantly across Europe: 223 acute care hospitals were closed in Germany, 308 in France and 67 in Italy.
The rate of acute care hospital beds per 100,000 inhabitants in 2009 in Europe was 372.5 (Chart 10). The highest figures were observable in Austria (557.1), Germany (565.7), Bulgaria (507.7) and Lithuania (501.9); the lowest figures were in Finland and Sweden (183.0 and 203.7, respectively).
Between 2000 and 2009, the number of acute care hospital beds per 100,000 inhabitants in Europe registered an average reduction by 15% in both EU15 and in EU12, with the only exceptions being Greece, whose value increased by 8.3% and The Netherlands, where it remained stable. Values reduced by almost a third in Estonia (-34.9%), Latvia (-29.5%), Hungary (-29.4%) and Italy (-28.0%).
The most relevant bed reductions occurred in the surgical and medical groups of specialties, which together represent far more than half of acute care beds. The reduction in the surgical specialties was approximately 10%. The reduction in the medical specialties was less consistent in the different European countries; however, it was particularly high – between -30% 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. In 2008, the rates of acute care hospital admissions in the European countries were quite dissimilar, ranging from 9.2% in Cyprus to 26.7% 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 2008, the average length of stay in acute care hospitals roughly ranged from 5 to 8 bed-days, with smaller values in only Denmark, Finland and Malta (from 3.5 to 4.8).
Between 2000 and 2008, almost all countries reduced their rates of admission or at least stabilised them. Many of them were also able to reduce the length of stay, the EU average improved (decreasing from 7.5 bed-days in 2000 to 6.7 bed days in 2008), the EU15 average improved by 0.9 bed-days and the EU12 average improved by 2.0 bed-days.
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 a too short length of stay may increase the risk of re-admissions, with a consequent waste of resources for both the hospital and the patients and his carers. At the same time, a too long length of stay may be indicative of inappropriate hospital settlement, causing similar waste of resources. 
Chart 11 compares the rate of hospital admissions and the average length of stay in 2008. The average European figures indicate a mean rate of admissions by 15.7 per cent and a mean length of stay by 6.7 days. The foremost variations between countries concern the admissions.  A cluster of countries, encompassing EU12, presents a number of admission slightly higher than the average. The smallest countries seem to be more successful in finding a good balance between these two indicators, while only Austria and Germany seem to register long hospital stay and high admissions rates. 
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 2008, the average acute care occupancy rate in Europe was 75.5%, but the gap between the highest and the lowest rate was 30 percentage points (Chart 12). Between 2000 and 2008, there were not consistent trends in Europe: the average rate of acute bed occupancy in EU decreased by 1.1 percentage point, the other values were encompassed between +6.8 p.p. and +5.7 p.p. in Cyprus and Ireland and -10.0 p.p. and -5.3 p.p. in The Netherlands and Germany. 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 over the next decade due to ageing, while several countries, especially in Central and Eastern Europe, are experiencing migrations of their 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 Organizations and EU are discussing the possible impacts and achievable solutions to these issues. 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 2009 highlights the presence of about 1,650,000 doctors and 2,900,000 nurses, with an average rate of about two nurses per each doctor (Chart 13). 
In 2009, EU15 had 346.3 physicians and 905.6 nurses per 100,000 inhabitants and EU12 had 271.6 physicians and 596.0 nurses per 100,000 inhabitants. Almost all the EU12 Member States had a share of physicians lower than the EU average, with the only exceptions of Bulgaria (369.0), Lithuania (365.1) and Czech Republic (356.0), and a share of nurses by 1 to 3 percentage points lower than the EU average, with the only exceptions of Czech Republic and Slovenia, which values equalled the average. Between 2000 and 2009, the number of physicians per 100,000 inhabitants increased by 15.1% in EU15 and by 3.3% in EU12.
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. Austria, Lithuania, Spain and Bulgaria had in 2009 the higher rates of physicians and at the same time some of the lower rates of nurses per 100,000 inhabitants. Conversely, countries where the shift of competencies from physicians to nurses is advanced – in particular UK, Ireland and Finland – registered in 2009 among the lowest rates of doctors per 100,000 populations, and some of the higher rates of nurses (Charts 14 and 15).
In 2009, doctors working in hospitals were 50% to 60% of the total, with the highest rates registered in France (76.1%) and in Denmark (71.0). Even if complete data for nurses are not available for many countries, figures suggest that in 2009 nurses working in hospital were on average 60%, this value being between 42.1% in Ireland and 100% in Austria.
Relevant variations did not happen between 2000 and 2009, except in Greece, which registered a significant reduction in the number of physicians working in hospitals (-10.0 p.p.) and in Lithuania and Spain, which had a considerable increase (+10.0p.p. and +8.1p.p., respectively). 
In 2009, approximately 10 physicians and 32 nurses graduated per 100,000 inhabitants (Charts 16 and 17). However, the values across countries varied greatly. The number of physicians graduated per 100,000 inhabitants ranged from 23.6 in Austria to 6.6 in Bulgaria, with a value particularly high in Cyprus (59.5). The number of nurses graduated per 100,000 inhabitants ranged from 69.4 to 58.7, respectively, in Switzerland and Austria and 4.9 in Bulgaria, with a value particularly high in Slovakia (152.0).
Compared to 2000, the average number of physicians graduated in the EU per 100,000 inhabitants increased by 6.4%, while the number of nurses graduated per 100.000 inhabitants increased by 18.9%, with a rate particularly high in EU12 (51.1%). The number of physicians graduated per 100,000 almost doubled in the Baltic countries (at least 72% of increase), even though the value in 2009 remained below the average. Conversely, the highest increases in the number of nurses occurred in France, Italy and Poland. Especially in the last two cases, these rates mirror the introduction and extension of the university-level education for nurses. However, especially in the last two cases, the value in 2009 remains far below the EU average.