Health Service Delivery – Comprehensive Study Notes

Course Logistics and Context

  • Lecture part of a modular course on the “building blocks” of health-care systems.

  • Date: session on service delivery; one block on medical products still to come; June 10 guest lecture by Will Quentin.

  • Lecturer needed to pre-record / use microphone because of schedule conflict.

Central Quote on Good Health Services

  • Source: WHO definition.

  • Good services: • effective • safe • quality • personal & non-personal interventions • delivered to those who need them • at the time/place of need • with minimum resource waste.

  • Emphasises that access alone is insufficient—services must be needed and high-quality.

Importance and Interlinkage of Service Delivery

  • Delivery sits at the centre of the WHO 2000 “green framework”.

  • Strongly inter-linked with other outcomes (accessibility, quality, efficiency, population health).

  • Still widely misunderstood by policy-makers who equate “more facilities” with “better care”.

Key Questions in Service Delivery Classification

  1. What is delivered? – The function or mode of provision (inpatient, day care, outpatient, home-based).

  2. By whom is it delivered? – The provider (hospital, rehab centre, solo practice, mixed ambulatory centre, etc.).

  • Essential to keep the two dimensions separate; everyday language often confuses “hospital” with “inpatient”.

System of Health Accounts – Functional Classification (HC)

Top-level functions (HC 0-HC 9):

  • HC1 Curative care – General vs specialised; subdivided into:
    • Inpatient
    • Day care
    • Outpatient
    • Home-based

  • HC2 Rehabilitative care – Also split by the 4 modes.

  • HC3 Long-term care (health) – Health component of LTC only; social components counted elsewhere.

  • HC4 Ancillary services – Lab, imaging, transport; often “dislocated” from the patient site.

  • Remaining codes (HC5-HC9): medical goods, preventive care, governance/financing, n.e.c.

Complexities & caveats

  • Rehabilitation often embedded in acute stays ⇒ hard to separate.

  • Food & accommodation: counted as inpatient only when medical activity predominates (contrast to hotel costs).

  • LMICs/Japan examples where meals are paid separately.

System of Health Accounts – Provider Classification (HP)

Primary providers

  • HP1 Hospitals → subdivided: general, mental-health, other specialised.

  • HP2 Residential LTC facilities.

  • HP3 Ambulatory health-care providers:
    • Medical practices (GP, specialists, other physicians)
    • Dental practices
    • Other non-physician practitioners
    • Ambulatory centres (dialysis, imaging, mixed medical centres)
    • Home-health providers.

  • HP4 Ancillary service providers – lab, radiology, transport.

  • HP5 Retailers of medical goods.

  • HP6 Preventive-care providers (if organisationally separate).
    Secondary providers

  • HP7 Administration & financing bodies.

  • HP8 Rest of economy—entities whose primary activity is not health.

  • HP9 Rest of the world—cross-border services (e.g.
    German SHI pays Dutch hospital).

Terminology tip

  • Outpatient = mode of service, whereas ambulatory = type of organisation.

Distinguishing Outpatient vs Inpatient Care (WHO)

  • Outpatient: patient not confined to a bed; includes home visits, minor surgery, first aid, preventive/palliative activities.

  • Inpatient: formal admission & ≥ 1 night stay; includes accommodation only if medical care dominant.

  • Note: inpatient ≠ “complex”—complexity belongs to tertiary concept, not the inpatient definition.

Common Misconceptions About Hospitals

  • Hospital ≠ pure inpatient provider; many European hospitals deliver large outpatient volumes.

  • Germany & Bulgaria are outliers where > 90 % of hospital spending is on inpatient care.

Typologies of National Service-Delivery Models

(Simplified graphic by lecturer)

  1. “Red/Right” model – Germany, Austria, Belgium, France, Switzerland.
    • Hospitals ≈ inpatient only.
    • Ambulatory sector split into many small GP and specialist practices.

  2. “Yellow” model – e.g.
    Netherlands (historically), Belgium (earlier).
    • Hospitals provide both in- & out-patient; ambulatory practices small.

  3. “Green” model – Nordics, UK, Spain.
    • Hospitals mixed; ambulatory providers organised in larger centres; specialists mainly inside hospital.

Country Case Illustrations

  • Finland: few hospitals; municipal health centres crucial; some have beds; vast distances (500 km to next hospital in Lapland). Specialists mainly hospital-based.

  • Netherlands: all specialists financially & organisationally inside hospitals; GP practices consolidating; 1⁄3 single, 1⁄3 duo, 1⁄3 ≥3 physicians (trend to larger).

  • France: self-employed GPs & specialists; nurses may run their own ambulatory services; public & private hospitals share acute MSO care.

Expenditure Patterns by Provider & Service Type

  • Hospital share of total health spending ranges from ≈ 50 % (Cyprus, Croatia) to 27 % in Germany (lowest).

  • Germany: 92\% of hospital € go to inpatient care; Denmark: 51\% ⇒ different activity mix.

  • Example calculation: Denmark’s inpatient share of total spending 0.45 \times 0.51 = 0.23 (23 %). Germany: 0.27 \times 0.92 \approx 0.25 (25 %).

Primary Care: Concepts, Roles, Actors

Definition (Primary Health Care Performance Initiative)

  • First contact, people-centered, comprehensive, continuous, coordinated, accessible.

Actors by income level

  • HICs: GPs, paediatricians, gynaecologists, ophthalmologists, dentists + nurses, pharmacists, physios, midwives.

  • LMICs: community health volunteers, CH nurses, physician assistants; physicians often absent from peripheral centres.

  • Complementary & traditional providers may be integral (e.g.
    birth attendants).

Primary Care vs Primary Health Care

  • Primary care (pink circle): clinically oriented curative-plus-prevention, coordination/gatekeeping.

  • Primary health care (green circle, Alma-Ata): broader population & intersectoral tasks—sanitation, health promotion, vaccination campaigns, advocacy.

Gatekeeping and Patient Choice

  • Gatekeeper: professional (usually GP) overseeing care, authorising specialist/hospital referral.

  • Objectives:
    • Control costs & unnecessary interventions.
    • Assure continuity & coordination.

  • Country spectra:
    • Mandatory registration & gatekeeping: UK, Netherlands, Denmark, Finland, Spain, Baltics.
    • Financial-incentive models: France, parts of Germany (disease-management or GP contracts).
    • Free access: Germany, Austria, Switzerland, etc.

  • Ongoing German coalition plan: move toward stronger primary-care orientation.

Measuring Strength of Primary Care (Kringos et al.)

7 dimensions (governance, economic conditions, workforce, accessibility, comprehensiveness, continuity, coordination). 77 indicators across 31 countries.

  • Map outcome: “strong” in UK, NL, Denmark, Finland, Spain; “weak” in Austria, Hungary, SE Europe; Germany, France, Italy = medium.

  • Austria, France, Norway have launched reforms in response.

Choice of Primary-Care Provider

  • Some systems restrict choice to geographic catchment (classic UK model – later relaxed).

  • Others allow free choice but weaken gatekeeping.

  • Trade-off: larger choice may coexist with mandatory registration to enable coordination.

Evolutionary Trends in European Service Delivery

  • 1990s Eastern Bloc: polyclinic & hospital-centric; Western Europe: solo practices + many local hospitals.

  • Current converging trends:
    • Fewer, larger hospitals focused on complex inpatient care.
    • Expansion of health centres for outpatient/day activities.
    • Shift of tasks from physicians to highly trained nurses (delegation → substitution).

  • Denmark builds new “rural hospitals” with zero beds (functionally health centres) for access.

Key Indicators Used to Monitor Service Delivery

Structure / Inputs

  • Beds per 1,000, capital stock, equipment.
    Process / Operating

  • Discharges or admissions

  • Average length of stay (ALOS)

  • Outpatient consultations per capita

  • Day-case share

  • Bed-occupancy rate.

Cross-Country Comparisons

Beds (EU data)

  • Highest: Bulgaria & Germany ≈ 8\text{ beds\/1,000}.

  • Lowest: Sweden, Netherlands, Denmark ≈ 2\text{ beds\/1,000} (factor ≈ 4).
    Cases

  • Germany ≈ 250 inpatient cases\/1,000; EU avg 170; Denmark lower yet treats beds more intensively.
    Substitution myth

  • Scatter plot shows most countries with high inpatient use also have high outpatient visits; little evidence of straightforward substitution, exceptions: Italy, Netherlands, Spain.

The Dutch Transformation

(2000-2012)

  • Total admissions ↑, but one-day admissions surpassed “clinical” inpatient.

  • ALOS fell from 8 → 5 days.

  • Achieved via policy pressure & payment incentives.

Average Length of Stay Across OECD

  • Longest: Korea (18 d), Japan (16 d).

  • Central-Europe cluster: Hungary, Czechia, Germany, Austria (≥ 8 d).

  • Shortest: Sweden, Denmark, Netherlands (≈ 4-5 d).

Example Condition – Spontaneous Delivery

  • Hungary 4.9 d vs Netherlands 1.5 d vs UK 1.6 d ⇒ cultural/clinical practice, not pathology, drives gap.

Day-Case Surgery Share

  • Cataract: many countries ≈ 100 %; Germany mid-range; Bulgaria/Romania low.

  • Tonsillectomy: Germany low day-case share; Nordic & UK high.

Policy Debates & Future Directions

  • Concentration of complex inpatient care needs regionalisation & fewer hospitals.

  • Outpatient/day services must remain geographically accessible ⇒ growth of community health centres.

  • German “Level 1e” proposal: rural hospitals repurposed mainly as 24⁄7 access/outpatient hubs.

  • Key design questions: emergency cover, specialist availability, financing alignment, patient acceptance.

Summary of Main Takeaways

  • Service delivery analysed along two SHA dimensions: function (HC) & provider (HP).

  • Inpatient/outpatient distinction purely by overnight stay, not complexity.

  • European countries display wide variation in bed supply, case rates, ALOS, day-surgery uptake—reflecting policy and professional culture more than epidemiology.

  • Strengthening primary care (clear roles, gatekeeping, coordination) is a shared reform trend.

  • Evidence indicates:
    • Strong PC systems correlate with better coordination & potential cost containment.
    • Bed reductions + day-case expansion feasible without harming access if outpatient infrastructure exists.

  • Ongoing challenge: balance centralisation of complex care with local accessibility, especially in rural areas.

Next lecture: Medical products (devices & pharmaceuticals).