Shifting from quality of hospital care to keeping people out of hospitals

A new transition from hospital productivity and hospital expansion, to focusing on quality and keeping people out of hospitals is warranted

Besides setting up measures to strengthen quality in the hospital sector, another key priority for Turkey will be to shift incentives and preferences for treatment that tends at present to be provided in hospitals towards other care-delivery settings particularly when hospitalisation could either be prevented, or care be delivered more cost-effectively in primary care settings (Chapter 2).

The data presented in Section 3.1 suggest that the Turkish health-care system is at present very much centered around hospital care. Turkey is one of the few OECD countries that continues to see expansion in the number of hospital beds. Not only is capacity rapidly growing, but also patients have historically had strong preferences for visiting emergency and secondary care including for minor ailments. Patients are, in theory, subject to a copayment if they visit hospitals without a referral. However, this does not seem to offer sufficient incentive for patients to use the primary care sector, so that the majority of outpatient visits tend to be for problems that could easily be dealt with at the primary care level (Methat et al., 2011).

Recent government plans have emphasized the expansion of hospital capacity, with the establishment of new hospitals and incentives to attract foreign investment. The combination of plans to expand hospital capacity, doctors’ incentives for higher volumes as an important source of income (see Chapter 4), and peoples’ preferences for hospital services over care in primary care settings could result in escalation of hospital volumes beyond what is medically appropriate or desirable, particularly for those with minor care needs or in need of chronic care.

Having now achieved universal health coverage, and having had considerable success in encouraging high levels of productivity in the hospital sector, the focus should shift to keeping patients, especially those with chronic as opposed to acute care needs, out of hospitals. While the number of hospital beds in Turkey is still among the lowest in the OECD, it is important to note that nearly all OECD countries are now downsizing their hospital sector. Turkey is in the unique position of being able to avoid recreating a health-care system that might be ill adapted for addressing the future needs of populations living longer and with more chronic conditions. Setting aside payment systems and financial incentives that are reviewed in Chapter 4, the section that follows examines three possible avenues for reform to facilitate this process.

Referral systems and care pathways could be further strengthened in Turkey

Gatekeeping can play an important role in reducing costs, steering demand for specialised services in a way to ensure the appropriate use of different levels of care (Paris et al., 2010). While the effectiveness of gatekeeping systems depends on several factors - such has the ability of primary care doctors to act as good agents managing and co-ordinating the follow-up of patient care, and on the information available on the quality and prices of services supplied by providers of secondary care (Paris et al., 2010) - strengthening referral systems and care pathways has the potential of helping to channel patients towards care that is most appropriate for their condition.

Turkey is one of the few OECD countries without an obligation or strong financial incentive to visit a primary care doctor before accessing hospital services (Table 3.2). Thus far, Turkey has introduced a waiver from copayments at secondary-level facilities if the patient has a referral from a primary care physician. Demand-side payment incentives - such as higher copayments for patients that access hospitals without a referral or without having visited the primary care level - can make direct access to hospital care more costly. Nonetheless, their efficacy is questionable if patients are ill-informed about the importance - and potential for cost-saving - of consulting a family physician first. Demand-side payment incentives are also less effective if the requirement to visit a family physician before seeking specialist care is not first formalised in gatekeeping systems; and if primary care physicians simply refer indiscriminately patients to higher levels of care instead of effectively steering them to the most appropriate services.

Table 3.2. Turkey gatekeeping rules are weak

Primary care physicians referral to access secondary care

Required

Incentives

No requirement, no incentive

Are patients required or encouraged to register with a primary care physician?

Required

Denmark, Finland, Ireland, Italy, Netherlands, Portugal, Slovenia, Spain

Czech Republic, Turkey

Incentives

Australia, New Zealand, Norway, Poland

Belgium, France, Switzerland

No requirement, no incentive

Canada, Chile, United Kingdom

Austria, Germany, Greece, Iceland, Israel, Japan, Korea

Source: Elaborated from authors based on data from the OECD Institutional Characteristics of Health Systems Database and information from Turkey.

The Ministry of Health should relinquish responsibility for directly managing hospitals and focus on monitoring

The Ministry of Health owns and controls most of the secondary services in Turkey. Until November 2011, responsibility for the operational running of ministry-owned hospitals was also held centrally. Recent reforms have sought to split the functions of policy making/regulation from that of management and delivery of hospital services by establishing a separate but affiliated Hospital Agency. To facilitate the implementation of the new governance structure, possible future directions may involve three key steps:

First, the Ministry of Health’s principal role in the management of hospitals should move to one of oversight, over the activities of both the public and the private sector. While the General Directorate for Health Services in the Ministry of Health is responsible for monitoring, setting guidelines and inspections for the health system as a whole, these activities are still under development for public hospitals, and their reach over private hospitals is limited. Similarly, the Health Information System Directorate is primarily focused on public hospitals, while there are relative few returns from private providers on their quality measures system (Saglik Net). The Social Security Institution collects a wealth of data on utilisation, reimbursement and treatments, but has limited ability to act as a strategic purchaser making effective use of these data.

Second, the ministry should allow the Hospital Agency to function entirely as an arms’ length organisation, autonomous from the Ministry of Health. To date, the ministry maintains strong linkages with the Hospital Agency, possibly because public hospitals depend on the Ministry of Health for funding. Public hospitals still enjoy relatively little autonomy; for

example, public hospitals have little say in decisions concerning hiring and firing of clinical staff and have limited margins for modifying payment for staff. Hospital manager and directors are chosen among chief physicians. With such limited autonomy, and a centralised governance model, it is difficult for the Hospital Agency to fully take onboard their independent role while the ministry’s focus remains squarely on the public hospital sector. The establishment of Public Hospital Associations in each province, and associated reforms, does have the potential to give hospitals in each province greater managerial responsibilities and accountability for performance to hospitals, and should be fully exploited.

Box 3.1. Organisational changes affecting public hospital facilities in Turkey

One of the key components included in the Turkish’s Health Transformation Programme was the introduction of autonomous public hospitals. While other reforms have been effectively implemented since 2003 (e.g, the establishment of a system of family physicians and the extension of health coverage to the entire population), reforms in the public hospital systems have been moving more slowly. Following the 2011 and 2012 organisational changes to the Turkish Ministry of Health, a new semi-autonomous affiliated agency responsible for all public hospitals was established, the Turkish Public Health Institution. This agency is expected to oversee public hospitals across the country, which are supposed to take semi-autonomous status.

Under the new arrangements, Turkey’s 81 provinces each have at least one Association for Public Hospitals, and each hospital (and hospital managers) is to be held accountable for the performance - efficiency, effectiveness and quality - of their facilities. Beside performance-based payments for medical staff in hospitals, the new system is expected to make it possible to improve the ability of managers to recruit staff and purchase goods and medical materials. Each Association will have a general secretary responsible for the performance of the facilities under the association, and managers will operate at the Association- and hospital-level. Employment contracts between managers and the Association, and their renewal, are expected to be subject to positive assessment of the hospital performance on an annual basis. The Ministry of Health is expected to set performance criteria. Hospitals will be classified into five groups (A, B, C, D, E) by the Hospitals Agency, based on a range of criteria, including services provided. This classification will be the basis for performance assessments. Facilities will get a report card every six months based on their administrative, medical, financial and other performance. The contracts of managers might be terminated if a hospital is degraded to a lower classification level between two assessments; or if insufficient improvements are seen. For example, if a hospital in group D cannot move to a higher classification level after three assessments; and if a hospital in group E and cannot move to a higher level after two assessments.

The performance of each Association for Public Hospitals is assessed based on the performance of all facilities for which it has responsibility. If the performance of the hospital or hospitals under its remit is/are unacceptably low, the contract of the General Secretary will also be terminated. The contract of the head of the central Agency for Public Hospital Associations depends upon performance of all of the provincial Associations of Public Hospitals The system is due to be in full effect from 2014. At present, all general secretaries of Associations have been appointed and the legislative procedures have also been established.

Third, it would be advantageous for individual hospitals to be given more operational autonomy, although careful consideration ought to be given to decisions about granting greater financial autonomy. In 1995, there was an attempt to make the management of public hospitals autonomous by setting up autonomous board and structures. This however was cancelled by the Constitutional Court, and only implemented in a pilot project in Ankara. The establishment of autonomous management in other OECD countries has been associated with both positive and less favourable outcomes. Granting of autonomy to public hospitals can provide managers with the ability to take decisions and prioritise resource use for the benefit of their patients, but it can also encourage hospitals - particularly when they retain financial surpluses - to prefer better-off patients or more profitable hospital services. This suggest that decisions to move ahead with greater hospital autonomy, while desirable in many respects, should be accompanied by measures to ensure that less profitable activities continue to be delivered.

Greater decentralisation and responsibility for hospital services at local level would be desirable

The complexity and diversity of the care needs of the Turkish population means that decentralisation is a preferable governance model for hospital services. Turkey’s diverse geography and society means that healthcare needs vary greatly across the country. For example, the health needs of people living in sparsely populated rural areas may differ considerably from those of people living in major urban centres, or populations in wealthier areas. In this context, responsibilities and decisions regarding (hospital) care services should be placed closer to where health-care services are actually delivered, allowing for flexibility to adapt to specific care needs of the population at a local level.

A move in this direction has already occurred. Reforms in 2011 increased the role of decentralised levels of governments and created 87 Public Hospital Unions across the provinces, each having the responsibility of managing hospital care for the population of the province. The general secretary of the hospital union is contracted for two to four years and is responsible to the central public Hospital Agency for hospital care output.

This structure is relatively new, and it remains difficult to gather information on how it is functioning. While it has the potential to bring care planning closer to where health needs are, the hospital unions do not seem to have the data or the information upon which to base their decisions, nor do they have the authority to plan on the organisation of hospital activity across the provinces, which remains a highly centralised matter. Unions have hardly any authority to hire and fire staff, for example, and have little purchasing autonomy. It would be desirable for the government to create a proper road map for strengthening the autonomous role of hospital unions, devolving financial autonomy and management. Examples of hospital decentralisation that Turkey could draw upon include hospital trusts in England, Australian local hospital networks, and experiences in New Zealand and France.

Last, the establishment of hospital unions has created a separation between hospital and community care (which is managed by provincial health directors). In the longer term, it would be desirable for the hospital unions to be linked to the provincial health structure more fully, and to take a broader role in guiding strategic planning for all hospital activities, including by taking into account private hospital activities.

 
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