Monday, 4 September 2017

Do we need "bonsai" hospitals?

Joan Escarrabill

The ideal size of the hospital and the minimal activity (number of procedures) it has to do to ensure quality is a recurring debate. Sometimes the issue of the hospital size is related to the primary care’s ability to solve and, therefore, the possibility of closing acute beds (and redistributing the budget that was intended for its operation). In the 2009 EESRI edition, in Table 10 (page 21), there’s a very significant information: the number of acute beds per 1,000 inhabitants. According to this document, in Catalonia we have 2.4 beds per 1,000 inhabitants and in the whole of Spain 2.5. Only Turkey (2.3) and Finland (1.9) have fewer beds per 1,000 inhabitants than we do. Despite the data, there are people who insist on the convenience of closing acute beds if the primary care resolution capacity increases. It seems to me that there’s a better question: too many beds or too many hospitals?

My answer (tentative and open to any revision) is clear: if there’s too much of anything, it’s the hospitals not the beds. The "bonsai" hospital is a reproduction of the large hospital, but reduced to the minimum expression. The "bonsai" hospital wants to have all basic services (i.e. a representation of all basic services) but often has difficulty delivering quality coverage (which doesn’t automatically mean more beds, it means more quality). The "bonsai" hospital is like a local icon that is justified by historically provided services (which, of course, were very valuable in another context of space and time) or by the effort that it took to build it. But what to do with "bonsai" hospitals when the context changes (a tunnel, a road, the difficulty of access to complex technologies or the shortage of qualified professionals)?

The political scientist Victor Lapuente has published a very interesting book "The return of the shamans". His proposal to address the problems is aimed at the diversity of experiences and, through the comparison of the results, making incremental improvements (this is called the explorer's mentality). He contrasts this position with that of the shaman who’s more interested in standardizing and creating general proposals applicable everywhere. The problem of "bonsai" hospitals can be solved in this context, from very simple premises: diversity without atomization, concentration without uniform centralization. Bringing services closer to the citizenry doesn’t mean having all the services next to their homes. Everything close by, but with an uncertain quality, or everything accessible at a reasonable distance depending on the complexity?

We need different ways of delivering health services (although this position, at the moment, contrasts with different trends that point towards a homogeneous will). Hospital resources should be concentrated towards a critical mass that ensures patient safety, effectiveness, and good patient experience and this can be done in various ways. Looking at how our neighbour provides services is a good way to learn and find shortcuts for innovation. If we are all equal, there’s not much room for learning (and, furthermore, Darwin tells us that homogeneous populations are headed towards extinction). It’s also a good innovation exercise to rethink the role of existing structures after the concentration of services for acute care. A good emergency service, good surgical offices, ambulatory surgery, sub-acute beds, a virtual connection hub with specialists or devices more open to community health could be some alternatives to be promoted.

This is not new at all. The same Lapuente gives the example of the concentration of municipalities in the Nordic countries, with this same criterion, away from the unifying centralization. In our country, in addition to concentrating hospitals, we should also concentrate municipalities (and I don’t know which of the two proposals is more difficult).

Of course, in the case of the discussion about hospital beds, the hypotheses must first be tested before opening or closing structures, as suggested by a successful BMJ Editorial.

PS: Regarding this subject, one can claim that it needs a good orchestra direction, but I prefer a jazz group: harmony in an apparent disorder, as Tete Montoliu (1933-1997) showed.

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