Because such political seppuku would be, without a doubt, a reduction in the number of hospital beds, leading to a reduction in the number of hospitals, which today seems to be the one reasonable solution that could realistically improve the financial situation of hospitals, and thus the entire health care system... also in terms of quality.
NIK audit results.
The results of Inspection P/22/048 "Functioning of county hospitals", which was undertaken on the Supreme Audit Institution's own initiative, are very interesting[1].
According to the results of the audit, as of June 30, 2022, there were 313 district hospitals that provided health care services financed by the National Health Fund. Of these, 297 showed liabilities.
According to NIK data, the number of district hospitals located across the country varies widely, ranging from eight in Lubuskie Province to 44 in Mazowieckie Province.
The indicated iconography, in general, shows how large the number of public hospitals is, not just county hospitals.
In order to obtain information on the operation of county hospitals, the Health Department of the NIK sent an inquiry to 275 county governments, which were the creating authority for them.
The questionnaire was completed by 223 counties (i.e. 81.1% of the surveyed units), which indicated that there are 249 "county hospitals" in their territory: 178 SPZOZ and 71 commercial companies.
As the NIK points out, although the financial performance of county hospitals improved in the 2018-2021 period, the year 2021 closed with a net loss for nearly half of county hospitals. Better financial results were recorded by hospitals run as independent public health care institutions. Nearly 60% of county hospitals at the end of 2021 had liabilities due, of which 36% had liabilities above PLN 1 million. In 2018-2022 (H1), 30% of hospitals had a unit construction project with a cost estimate of more than PLN 10 million. In addition, a shortage of doctors was indicated by nearly 80% of hospitals.
Growing debt of SPZOZ and district hospitals.
These are very interesting results, which cannot be considered in isolation from other data, i.e. those from the Ministry of Health[2] and information from the report "Financial situation of county hospitals in light of the amendment to the law on the manner of determining the lowest basic remuneration of some employees employed in medical entities," prepared by the Union of Polish Counties, the National Association of Employers of County Hospitals together with the City of Warsaw[3].
According to data from the Ministry of Health, the debt of hospitals (Independent Public Hospitals) is increasing year after year. Even taking into account the decline in the purchasing power of money, a comparison of their debt from 5 years ago (it was PLN 11.8 billion in Q3 2017) with "fresh" data (in Q3 2022 - PLN 19 billion) shows the scale of the problem.
Total liabilities of hospitals rose to PLN 19 billion in Q3 2022, an increase of PLN 1.1 billion in just three months. This is an alarmingly high jump. Debt hasn't grown so rapidly before, if you don't count the fourth quarter of 2020, when there were problems in hospitals' settlements with the National Health Service due to the coronavirus pandemic.
On the other hand, according to data specified in the report "Financial Situation of County Hospitals in Light of Amendments to the Law on the Manner of Determining the Lowest Basic Salary of Certain Employees Working in Medical Entities," out of 211 county hospitals, as many as 191 recorded a loss related to core business in 2022. This compares with 172 hospitals recording a loss in 2021. The debt of county facilities increased to the amount of PLN 16 billion.
What are the reasons for the debt?
Of course, the reasons for this are attributed to various circumstances.
The lowest salaries of some employees of medical entities have risen again, and hospital managers are concerned that new valuations of services will not cover the cost of the increases.
Parallel to the cost of salaries, the prices of energy supplies, medicines, medical supplies are rising.
Are these actually problems? Without a doubt, yes.
However, according to the NIK audit cited at the outset, moreover, the shortage of doctors was indicated by nearly 80% of hospitals, while the NIK audit showed that notoriously hospitals do not comply with staffing standards.
At the same time, according to the NIK, the total number of beds available to the audited hospitals increased slightly during the audit period (from 5918 in 2019 to 5996 - at the end of the first half of 2022). At the same time, there was a decrease from 2020 in the total number of inpatients (by 37.5%) and the total number of outpatients (by 23.5%) compared to 2019, which the NIK explained with the COVID-19 epidemic state introduced in the country, declared in March 2020. On the other hand, the share of medical workers in the total workforce slightly but successively decreased, and amounted to: in 2019. - 68.4%, in 2020. - 67.6%, in 2021. - 66.8%, and 66.0% at the end of the first half of 2022.
Even if the decrease in the number of patients was triggered by the COVID-19 outbreak shutdown, the increase in the number of hospital beds while there is a shortage of medical personnel is puzzling.
So are we in for another hospital debt relief? How many have there been? I don't think anyone can count anymore.
Personally, I am of the opinion that reducing the number of hospitals, while maintaining health care expenditures (which are steadily increasing) is the simple answer. The number of medical workers employed in hospitals will not increase overnight, but after all, with fewer hospitals, being able to meet employment standards would not be a problem.
I leave aside that the NIK audit shows that the shortage of doctors leads to pathologies, i.e. "Theaudit of the verification of working time standards and on-call staffing by medical personnel showed that in three hospitals, out of the 22 audited, the health safety of patients, as well as doctors, was not properly ensured. Doctors employed under civil law contracts were allowed to perform several days of uninterrupted on-call duty, and thus were not provided with proper rest."
Why do we need so many hospital beds?
Assuming that Poland's population is 38 million, according to the Danish model, there should be about ... yes, yes 105 hospitals. Well, okay, if we wanted to achieve the efficiency of the health care system at 3 times less, (taking into account cultural and demographic differences), 315 hospitals would provide care in Poland, while there are almost 580 hospitals in the network (which is about 100% more).
In Poland, there is currently one hospital per (statistically) 1.5 counties.
In 2022. Eurostat published "Statistics on health care resources - hospital beds."[4]
An analysis of the number of hospital beds in relation to the population shows that in 2018 there were an average of 538 hospital beds per 100,000 population across the EU-27 (Total number of hospital beds = inpatient (acute) care beds + rehabilitation care beds + long-term care beds + other hospital beds).
Poland is above average, i.e. provides 653 beds per 100,000 residents.
Among EU member states, Germany not only recorded the highest number of hospital beds (661,000; 2017 data), but also the highest number relative to population, with 800 hospital beds per 100,000 residents (with this being due to the high proportion of private nonprofit and for-profit hospital entities). Bulgaria, Austria and Hungary also recorded more than 700 hospital beds per 100,000 residents, with Romania's rate slightly below that.
Ireland (excluding psychiatric beds, excluding beds in the private healthcare sector), Spain, Denmark and Sweden recorded the lowest number of hospital beds relative to population size in 2018, all below 300 per 100,000 population. At the same time, the quality of health services was not affected, as qualitative studies show (more on this later).
Poland is above the average, i.e. 653 beds per 100,000 inhabitants, which means that we have more than 2 times as many hospital beds as Ireland, Spain, Denmark, Sweden. One could justify this if the referenced countries were self-sayers in terms of health care quality ratings. However, this is not the case.
Long-term care beds accounted for less than 15% of the total number of hospital beds in 2018 in most EU member states (no data for Portugal and Sweden), with only Hungary (17.4%), Croatia (17.4%), Finland (19.0%), Estonia (19.5%) and the Czech Republic (29.6%) recording a higher percentage.
In turn, contrary to demographic trends and the recommendations contained in the documents: the announcement of the Minister of Health of August 27, 2021, on the map of health needs and the announcements of individual governors on transition plans, the share of long-term beds in the number of all hospital beds in Poland is extremely small - it is the smallest in Europe[5].
Well, Dear All, we can therefore complain about the continued progressive indebtedness of hospitals, but until the number of hospital beds is reduced (and this will undoubtedly result in a reduction in the number of hospitals), every now and then we will return to the problem of indebtedness with a shortage of medical personnel.
And in the meantime, I will be waiting for the health minister who will have the courage to commit political seppuku and say directly, "This is how I will reduce the number of hospital beds and increase the number of long-term beds."
[1] https://www.nik.gov.pl/plik/id,28082,vp,30905.pdf
[2] https://www.gov.pl/web/zdrowie/zadluzenie-spzoz
[3] https://www.zpp.pl/storage/files/2023-06//cfbfcf40aac2ff8233d53aea8c64d8809574.pdf
