|Specialty planning in hospitals|
|Implemented in this survey?|
Specialty planning for hospitals is carried out in regions and has to be approved by the Board of Health. Specialties are either regional (provided by max. 1-3 hospitals per region) or highly specialized (prov. by max. 1-3 hosp. within the country). The purpose is to secure high quality, coherent patient pathways, efficient use of scarce resources, building-up and maintenance of expertise, research & development, and education. Still, care should be provided as close to patients as possible.
Specialty planning is about planning the division of tasks between various types of hospitals and between hospitals with different levels of specialisation. The purpose of specialty planning is to secure high professional quality in health care, coordinated patient pathways and efficient use of scarce resources, particularly manpower. In addition, the planning should promote the necessary build-up and maintenance of expertise, research and development, and education to secure a continuous development of each specialty. The planning should consider the supply of health services of a high quality with efficient use of resources as close as possible to the patient, and the planning should consider the necessary coordination and co-operation with all partners in the health care sector (Board of Health, 2008; Board of Health, un-dated document (1); Board of Health, un-dated document (2)).
Health Law of 2008: The Board of Health has previously issued guidelines as to specialty planning in public hospitals, but the new feature according to the Health Law of 2008 is that the board now has the authority to approve or reject applications from regions or private hospitals to run highly specialised or regional functions as opposed to less specialised functions. In collaboration with the regions, the professional medical societies, the corresponding professional nursing societies, and the Board of Health, have formulated requirements for each of the 36 specialties. The guideline for each specialty is based on a report from the relevant professional medical society and the regions, and it has been presented to an Advisory Committee composed of representatives from the professional medical and nursing societies, the regions, the Board of Health and the Ministry of Health.
Principles and criteria: Specialty planning should as far as possible be evidence based, and there is an increasing evidence for a correlation between high volume and high quality in health care, as well as there is evidence for the benefits of a cross-disciplinary cooperation. It is acknowledged, though, that there is not much evidence for the organisational solutions, and therefore much planning has to be based on knowledge and experience by the medical and nursing experts rather than on evidence based knowledge. A decision on the geographical placement of a specialty should be based on several considerations, including complexity of a function, frequency of the specific health problem and use of recourses besides more general considerations involving the total Danish health care sector (e.g., differences between regions as to capacity, development and geographical issues).
Definitions: A basic function is defined as care for health problems which only require health care of limited complexity in contrast to specialized functions, defined as either regional or highly specialised functions. A regional function can typically be placed in 1-3 hospitals in each of the five regions while highly specialised functions typically can be placed at 1-3 hospitals within the whole country. It is envisioned that in rare cases a function would be so complex, rare or expensive to establish and maintain, that it cannot be established in Denmark, and the patient has to be treated outside the country - or in a Danish hospital in co-operation with a foreign hospital.
Preconditions: It is assumed that all functional levels can be served by a number of general functions like diagnostic radiology, clinical biochemistry, clinical immunology and blood transfusion, clinical microbiology and others, including acute life-saving treatment.
Organization and follow-up: According to the Health Law 2008, the regions have the responsibility for running the tasks of hospitals. This implies that a region with specialty function also has the responsibility to supply health care from this function 24 hours a day all year round. This would require at least three specialists within a given specialty. If a region does not have a specific function, it must obtain an agreement with another region about treatment of its patients, or with private hospitals. As a general rule, elective and acute functions should be taken care of by the same hospital. It is moreover expected that a general co-operation across hospitals and regions will take place to secure a high professional quality, sharing of knowledge, efficient use of resources and a broad geographical coverage. For each function clinical guidelines should exist, and it is a goal to establish common national clinical guidelines for each specialty function. The Board of Health should receive a yearly report from regions and private hospitals with documentation of the fulfillment of requirements for running specialty functions. The revised planning rules should be seen in the light of the structural reform of 2007 with the introduction of five regions instead of a larger number of counties, and thus planning can be made within a widened geographical area. It should also be seen in light of the reorganised hospital structure with fewer acute hospitals and improved pre-hospital health care ( Pedersen, HPM report 13/2009).
According to the Health Law of 2008, the Board of Health formulates requirements for running specialty functions in public and private hospitals and also has the authority to approve such plans. A distinction is made between basic functions and specialised functions, which include either regional functions or highly specialised functions.
The objectives are to secure a high quality in health care as well as coherence in patient pathways and efficient use of scarce resources with due geographical considerations.
There exists an incentive for hospitals to keep highly specialized functions to attract highly specialized doctors and to attract patients. Likewise, there exists an incentive for the regions to keep specialized functions to earn more money.
Health professionals, Patients
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The policy follows a long tradition of specialty planning, but it is new that the National Board of Health approves the plans rather than just giving guidelines.
There is a general understanding among main actors of the need to have the specialty planning aproved by the National Board of Health due to the limited number of specialized doctors and the need to get routine experience through a minimum number of patients.
Specialty planning is a requirement according to the Health Law 2008. The fact that the Board of Health has the authority to approve such plans means that a stronger central regulation has been introduced.The parties behind the Health Law (Social Democratic Party, Social Liberal Party, Liberal Party, Conservative People's Party and Danish People's Party) agreed on planning in the hospital sector according to four basic principles: 1) High quality irrespective of time and place - specialised treatment should be placed in sustainable units, and acute treatment of the same high quality should be supplied irrespective of the time of day all year round. 2) A dynamic hospital sector - most treatment should take place as close as possible to the patient, and specialised health care should be introduced when routine and other professional requirements are fulfilled. 3) A robust hospital sector - specialised functions should be united, and existence of parallel functions which involves spreading of the expertise and requires more resources should be minimized. 4) Openness and documentation - public authorities should have the greatest possible access to documentation of activity, quality and effectiveness; regions and hospital department should be able to learn from each other; and patients should be confident that treatment is carried out with a high quality (Board of Health, undated document (2)).
While the Board of Health previously issued guidelines concerning specialty planning, the Health Law 2008 required planning of hospitals' specialties involving approval by the Board of Health.
|Implemented in this survey?|
Overall, this new specialty planning can be seen in the light of the structural reform and the derived reform of the hospital structure with fewer acute hospitals, and a more centralised approach to the regulation of the health care sector. Planning of specialities in hospitals is linked to the planning of acute functions.
The approach of the idea is described as:
renewed: The need for a renewed specialty planning was derived form the structural reform 2007 and is stated explicitly in the Health Law 2008.
In general, there has been strong support for the specialty planning structure and process. In a few cases there have been protests from hospitals and regions against the decisions by the Board of Health to reject a specialty. This has involved highly specialized functions and acute care as well. As to acute care, the population in some areas and on some islands have feared a longer distance to acute hospitals.
|Danish regions||very supportive||strongly opposed|
|Professional medical societies||very supportive||strongly opposed|
|Social democratic Party||very supportive||strongly opposed|
|Social liberal Party||very supportive||strongly opposed|
|Liberal Party||very supportive||strongly opposed|
|Conservative party||very supportive||strongly opposed|
|Danish People's party||very supportive||strongly opposed|
Specialty planning has been made continuously in Denmark. The new feature is that the Board of Health has the authority to approve the plans, and the private hospital sector - although minor in Denmark - is included.
|Danish regions||very strong||none|
|Professional medical societies||very strong||none|
|Social democratic Party||very strong||none|
|Social liberal Party||very strong||none|
|Liberal Party||very strong||none|
|Conservative party||very strong||none|
|Danish People's party||very strong||none|
The five regions and their hospitals are involved in implementing the plans. It is expected that the implementation will be fulfilled by the end of 2010.
No formal evaluation is foreseen, but the fulfillment of the plans will be continuously monitored by the Board of Health. Regions arerequired to yearly hand in documentation of the fulfillment of the plans.
The planning can be expected to result in a more rational running of the hospital sector, a higher quality of hospital services and a more efficient use of resources. Although it is desired that care should be provided as close as possible to patients, a smaller number hospitals with specific specialties can be foreseen.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
|Specialty planning in hospitals|
Process Stages: Implementation
IST- Health Economics, University of Southern Denmark