Standpoint: Learning the lesson
Successful capital projects in Europe require much more than good architectural solutions, healing design and environmental sustainability, claims Bernd Rechel.
Each year, many billions of euros are spent on capital investment projects in the health sector across Europe, and this amount is likely to increase in the coming years, as many countries face a backlog of maintenance and refurbishment.
Nowhere is the need greater than in Central and Eastern Europe, where levels of capital investment have been particularly low over the last 30-40 years. When funds become available to address the long-standing lack of capital investment – for example through structural funds for new EU member states or the oil boom that countries like Russia or Kazakhstan are experiencing – there is a real danger that resources are not spent in the most effective and sustainable way.
Before rushing into building new facilities, there are some key lessons to be learnt from capital investment in Europe. What should precede any capital projects, is a comprehensive analysis of health needs and how these needs should be translated into services and appropriate facilities. Long gone are the days when hospital beds were seen as an indicator of a good healthcare system, such as under the Soviet Union, which placed great emphasis on a large number of hospital beds and physicians.
Health facilities should not be perceived mainly in terms of buildings, beds or specialties, but rather from the perspective of the patients who are treated in them and the processes delivered by the health professionals who spend their working lives in them.
This approach entails going beyond the single health facility and taking account of the whole trajectory of care. Far too often, capacity planning in the health sector fails to move beyond hospitals and does not take account of the overall health needs of the population and the spectrum of health services required to meet those needs.
Health facilities also often continue to be used beyond their functional lifespan and reflect outdated patterns of care – such as the large number of tuberculosis hospitals throughout the former Soviet Union that are at odds with modern approaches to tuberculosis treatment. Flexibility must encompass all aspects of health facilities, including their scale and scope, architectural design, supporting infrastructure, services to be provided, relationships with the rest of the health system, revenue ? nancing, and sources of capital investment.
Paradoxically, in a few countries, policy is moving in the opposite direction – the Private Finance Initiative in the UK involves contracts, which are speci? ed in great detail for the lifetime of a project, usually around 30 years, with very little scope for change. Effective capital investment requires intelligent financing mechanisms, both for services and capital. In terms of services, resource allocation should reward outcomes rather than capacity and provide a smooth patient journey across different levels of care.
With regard to capital, the cost, risks and value of capital have largely been ignored across Europe, with investment and revenue costs belonging to different streams, removing any incentive for hospital managers to manage assets efficiently. This traditional split is gradually eroding in many European countries, as hospitals are increasingly becoming responsible for their capital assets.
It is abundantly clear that successful capital projects require much more than good architectural solutions, healing design and environmental sustainability. They will need to be based on an assessment of health needs, comprehensive capacity planning, a whole systems perspective, systematised care pathways, anticipated flexibility and intelligent financing solutions.
None of the countries in Europe has perfect solutions for all these issues and those involved in planning major capital projects are well advised to try and ensure the long-term effectiveness and sustainability of anticipated health facilities.
Bernd Rechel is a lecturer at the London School of Hygiene & Tropical Medicine and a researcher at the European Observatory on Health Systems and Policies.