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ARCHITECTURE / <<€®yL®(MUM~J®U©MaL>>#7(I31])),2(0]9
ARCHITECTURE
UDC 725.51
Bulakh Irina Valerievna
PhD of Architecture, Associate Professor Department of Design of the Architectural Environment,
Kiev National University of Construction and Architecture ORCID: 0000-0002-3264-2505; ResearcherID:V-4802-2018; Spin-Kod: 9274-0113
DOI: 10.24411/2520-6990-2019-10152 EUROPEAN AND AMERICAN EXPERIENCE OF OPTIMIZING THE ARCHITECTURAL-URBAN
SYSTEM OF HOSPITALS
Today, European countries, in a gradual process of optimizing the capacity of hospitals, have achieved that the total number of hospital inpatient places has decreased, and the remaining are used for intensive treatment of a larger number of patients with the minimum acceptable and short-term stay of the patient within the walls of a medical institution. These changes were due to the three factors that made themselves felt in the 1960s - 1970s as a reaction to the need to contain costs and the emergence of new models of treatment and care: long-term patients, financially dependent elderly people were taken out of hospital treatment, restructuring was carried out treatment of acute cases, the role of outpatient treatment and rehabilitation outside the hospital walls has increased. Transfer of long-term patients outside the hospital. The changing model of care for the elderly and those with severe disabilities or mental illness, characteristic of many high-income countries, can be illustrated by the UK experience. In this country, the number of places intended for the treatment of acute cases and mental illness gradually decreased, while the capacity of nursing homes increased dramatically. The explanation may be the trend of "normalization", which began in the 1960s, when the model in which medicine served as a form of social control was rejected; instead, people in need of care sought to provide conditions as close to home as possible. This became possible after the invention of new drugs, which allowed patients with psychosis to live among healthy people. Later, the search for alternatives to hospital treatment was intensified under the influence of trends encouraging social care for the elderly.
A nursing home is an institution that provides long-term care, but not specialized treatment. A study carried out in ten countries with a high standard of living showed that 2-5% of the elderly receive care in nursing homes. Differences between countries are due not so much to differences in the characteristics of the elderly population, but to political decisions, the consequences of which are not always predictable. Some governments are actively subsidizing nursing homes, thus encouraging the outflow of old people from hospitals. However, the UK experience led to an unexpected result in the form of a sharp quantitative growth of private nursing homes. At the same time, the experience of Australia, where a similar policy was adopted two decades earlier, turned out to be less successful. Currently, many countries are seeking to find alternatives to nursing homes, encouraging those forms of care that would allow older people to stay in their homes for as long as possible.
Long-term care for mental patients. In most European countries, the number of patients admitted to psychiatric hospitals has decreased significantly since the late 1980s. This became possible due to the fact that new psychotropic drugs reduced the need for strictly protected psychiatric hospitals at the same time that the health care systems could not fully fund the costs of maintaining such patients. At the same time, opinions emerged about the inhuman and depersonalizing influence of the hospital environment. Changes began in the United States, where psychiatric hospitals became comparable in size to small cities. The number of inpatient psychiatric facilities per 1,000 people decreased from 2.1 in 1970 to 0.4 in the 1990s. The 1950s and 1960s recorded in history as the "human" phase, when long-term patients could be released from the hospital and returned back. The "radical" phase of the 1970s was characterized by the fact that hospitals, under the influence of financial constraints and in search of the best forms of treatment, again became "closed" and public care services began to provide basic assistance. The tendency to reduce the number of inpatient hospital places for the treatment of acute cases has been criticized and is still criticized. Hospitals began to resemble "turntables": patients are discharged ahead of time and then taken back; hospitals refuse admission to many seriously ill people; persons in need of inpatient treatment wait a long time for their turn; the functional difference between inpatient and outpatient treatment is not clear enough. In addition, the flow of people from hospitals to community and social care services is not accompanied by similar financial support. Thus, the conclusion from the attempt to reform the psychiatric hospitals of the United States may be as follows: the renovation of a psychiatric hospital to solve other functional tasks failed a large institution cannot be easily transformed into something new, even into the center of social care; the task of retraining hospital staff to perform functions of community or social care also revealed a difficult one; savings are often not redirected to social services; The closure of hospitals without a suitable alternative turned out to be fraught with serious dangers for patients, their families and society as a whole.
Reorganization of the inpatient treatment of acute cases. Reducing the capacity of hospitals is made possible by transferring inpatients to separate long-term care facilities, as well as by reducing the length of stay in the hospital for the treatment of acute cases. It cannot be said that a radical reduction in hospitals is suitable for all countries, for countries with dispersed rural populations, such as Norway, may still need a large number
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of small hospitals. Anyway, most Western European countries are seeking to reduce the capacity of hospitals or reduce the number of inpatient places. In many European countries, the closure of entire hospitals is considered too complicated. So, in Germany between 1991 and 1997. 7% of hospital beds were eliminated; however, almost no hospital was closed. The elimination of stationary places in itself does not provide significant savings because a significant proportion of hospital costs associated with the operation of buildings, equipment, etc. Only a few countries have decided to close a relatively large number of hospitals. Among such countries are the United Kingdom and Ireland, where in the 1980s and early 1990s the number of hospitals decreased by about a third.
In a few countries, the closure of hospitals was accomplished through the use of regulatory approaches. Thus, in Belgium, by decree of 1982, a maximum was set for the total capacity of the hospital, and health insurance funds were given the right to retrain some hospital places as "places of care", which require less funding than, for example, treatment of acute cases. Secondly, since 1989, an accredited Belgian hospital must have at least 150 inpatient facilities, which has reduced the number of small hospitals. In Denmark, change was stimulated by the development of interstate market relations. It is important to note that negotiations were conducted not on behalf of individual hospitals, but on behalf of entire countries; their result was the replacement of two or more small hospitals with complex and large institutions. Some success has been achieved through the use of planning approaches. In France, 26 regional councils were created, the purpose of which was to eliminate 24,000 places for the treatment of acute cases (a decrease of 4.7%). In 1994-1998 In the public and private sectors, 17,000 inpatient facilities have closed. This made it possible to develop other institutions that are more suitable to meet changing needs. Regional hospital agencies opened 15 new hospitals, 7 dialysis centers, 20 centers for people with Alzheimer's disease and 60 new oncology facilities.
The use of exclusively market strategies (the separation of purchases and supplies, the provision of autonomy to hospitals) slows down the pace of transformation by several factors: market relations do not pay attention to the needs of the population for medical care, but rather to managerial, corporate and professional interests; the manager of the hospital, having gained autonomy, receives a basis to oppose the closure of his institution, including with the help of influential doctors and local government bodies; withdrawal of funds can be counteracted without resorting to closing the hospital, but only by refusing to maintain buildings and equipment or by accumulating a deficit; closing large hospitals is an unpopular method for politicians. Transformations are particularly difficult in cases where property rights are decentralized and incentives are mixed. For example, in Switzerland, the decrease in capacity was not significant. In this country, funding comes from both tax revenues and health insurance funds, and property rights are shared between cantons, municipalities, and the private sector. In Italy, the pro-
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portion of inpatient places and hospitals varied by region. In some regions, difficulties in introducing the new have been attributed to competitive incentives that remain in conditions where many doctors work in both the public and private sectors. A policy based on encouraging the replacement of some forms of services by others has reduced the capacity of hospitals, but did not by itself lead to their closure. Among the often taken political measures is the expansion of outpatient treatment, as in Norway, or rehabilitation facilities, as in Germany. To facilitate the replacement of services, Germany abolished the former strict separation of inpatient and outpatient treatment.
The closure of hospitals is more likely in cases where instead of two or more hospitals a new institution is organized, often in a new location. As a result, it is possible to avoid the impression that one of the institutions turned out to be a "winner", and also to gain obvious benefits for staff who are interested in modernization. Such measures may also be necessary in cases where institutions built several decades ago (or even centuries ago) cannot be adapted to the needs of modern health care. For example, in Spain it was possible to close a number of old and very large hospitals by building new, not so large and more accessible facilities. In the USA, by contrast, hospitals have undergone very significant transformations over the past two decades, mainly due to mergers of small non-profit hospitals that are exempt from taxes. Since the early 1980s, intensified competition has reduced costs and prices in hospitals. The hospital merger process continued until the end of the 1990s, with an intensity of about 250 mergers per year. Reducing the very high costs of healthcare and hospitals in the United States is considered a merit of a managed medicine system; At the same time, among various groups, including the sick and doctors, discontent with the current situation is developing. The UK experience demonstrates the possibility of merging hospitals and an example of the consequences of their partial closure. As in France, the transformation was preceded by a preliminary analysis and a clear plan. Mostly the optimization took place due to the merger of individual hospitals, as a result of which the hospitals of a particular city were merged into a "hospital trust". It is much more difficult to close a separate, autonomous hospital than to eliminate an extra element revealed during the formation of a large hospital conglomerate. Similar measures were taken in Melbourne (Australia) in 1995, when 32 public sector hospitals were grouped into 7 associations; as a result, 9 hospitals were closed, and further merger and restructuring processes continued inside the associations.
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