Dishonorably discharged?

The lack of places at mid-term care centers is blocking up thousands of hospital beds Intermediate treatment facilities need to be improved, say specialists

Patients lie in the corridor of an emergency ward at a Madrid hospital.
Patients lie in the corridor of an emergency ward at a Madrid hospital.

At age 56, Roberto can barely move or talk. He suffers from Alzheimer’s, and has just been temporarily admitted into a long-term care facility in Gran Canaria. Before that, he spent seven months in a hospital even though he had been discharged much earlier than that. His daughter Carla, 34, refused to take him home: because of the advanced state of his condition, she could neither care for him personally nor afford a private nursing home.

Roberto and Carla are assumed names, but their case is real. So are those of the other 390 patients who remain in general hospitals throughout the Canary Islands well beyond their discharge date. The situation was recently disclosed by regional premier Paulino Rivero, but it is by no means exclusive to this part of Spain.

“Spain has not properly resolved the transition between the healthcare system and the social care system,” says David Casado of the Catalan Institute for Public Policy Evaluation, who has 15 years’ experience assessing social care services for the elderly, the poor and people with illnesses and disabilities.

“This is the healthcare system’s great challenge today,” adds Laura Pellisé, director of the Economy and Health Research Center at Pompeu Fabra University. “The challenge involves adapting to the needs of multiple pathologies and chronic patients, and moving on from the current system to one with greater continuity between the health aspects and the social aspects. It is a slow process and a global challenge.”

Hospitals are becoming increasingly more technical places focusing on fast patient turnaround. But on occasion, when patients get discharged, continuity of care is not guaranteed because there are no mid-term care facilities or residences available for them. “They are people whose social conditions make it impossible to take them out of hospital,” says Eduardo Zafra, author of several studies on the subject.

A rise in chronic and older patients

The Canary Islands are particularly lacking in intermediate care resources. Of the 7,663 hospital beds available in the archipelago, only 200 are for mid-to-long-term stays. The region also has the lowest rate of dependents receiving public assistance: 0.54 percent compared with a national average of 1.6 percent.

Spain has 31.1 long-term care beds per 1,000 inhabitants, coming in third to last among OECD countries, just ahead of Italy and Poland. The average is 49.5 beds per 1,000 inhabitants.

Twenty percent of chronic patients admitted to acute hospitals could have received assistance in mid-to-long-term care centers, where the cost per bed is six times lower.

Between 70 and 75 percent of health spending goes to deal with chronic diseases.

According to the 2009 European Health Survey, 45.6 percent of Spaniards aged 16 and older suffer from at least one chronic condition. Twenty-two percent suffer from two or more chronic conditions.

Chronic diseases are responsible for 80 percent of primary care consultations.

The average age of patients admitted to National Health System hospitals was 53.9 years in 2010, almost four times what it was in 2000. Omitting women admitted to give birth, the largest group was those aged 75 or over.

And so the patients remain in hospital, surrounded by technology they don’t need and failing to receive the low-to-middle intensity health or social care they require. Given the lack of alternatives, hospital stays are unnecessarily extended, and this has an impact on more than the patients themselves. Spending goes up: an acute care hospital bed costs six times as much as a bed in an intermediate care facility. And the more hospital beds are taken up, the longer the waiting lists for other patients requiring hospitalization.

It is not easy to gauge the extent of the problem in Spain. Besides the information offered by Rivero, there is little else to go on as no official data exists, the Health Ministry admits. It is a very different story in countries with a great tradition of transparency, such as Britain, where the National Health Service provides data on bed blocking on its website. Records show that current figures are the highest in the last three years: in November of last year there were 4,190 patients in England who were well enough to be discharged yet continued to take up hospital beds. The delayed transfers were basically due to late patient assessments and a lack of vacancies in care homes.

In Spain, the Edad & Vida Foundation, which comprises health insurers and elderly care home companies, estimates that 5,238 acute patient beds are being occupied by people who need social care, “at a cost of 1.5 billion euros for the National Health System.”

Experts consulted by EL PAÍS underscored two key elements to bed blocking in Spain. One is a shortage of beds for mid-to-long-term care patients. The latest Health Ministry data, available for 2011, shows that for every 10 beds for acute patients in public hospitals there is just one bed in mid-to-long-term care facilities, which are the best place for long convalescences or physical rehabilitation.

“There are very few, and in the end the acute hospitals play this role,” says Agustina Hervás, head of the social care unit at Virgen del Rocío Hospital in Seville.

The other major bottleneck lies in the dependents system, built to assist people who cannot take care of themselves. The waiting list for social services covered by the law (residential care, day centers, home care and so on) affects 190,000 people who are eligible for aid but have yet to receive it.

The needs of chronic and dependent patients are a result of the medical success in handling disease. The rise in life expectancy has also increased incidences of chronic illness: the prevalence of diabetes rose from seven to 17 percent in 10 years in people 75 years and over. Over 25 percent of people 45 and older also suffer from more than one chronic illness. And there are growing numbers of elderly people with serious conditions that make them dependent on others for care.

The transition between the healthcare and social care systems is poor”

Faced with this scenario, hospitals are developing several strategies to prevent bed blocking, says Bernardo Valdivieso, head of planning at La Fe Hospital in Valencia. One is to follow up on chronic patients at risk of destabilizing, in order to reduce the risk of them being admitted into hospital because of an emergency. The management of the discharge process is also being improved. At large medical centers there are teams who start planning the discharge of patients from the moment they are admitted, so that if any kind of social care is expected to become necessary, it will be available when it is needed. Another strategy is home hospitalization.

But adapting to the needs of chronic patients with several conditions is not something that hospitals can do by themselves. Not even the health services can, not without some extra help.

“There must be greater continuity of care, and that requires reorganizing health and social care, and reassigning the roles in primary and specialized care and in the social services, all of which must lead to an integration of health and social care," says Laura Pellisé.

To date, the greatest efforts in that direction have been made “in Catalonia and the Basque Country,” she adds.

Estimates say over 5,000 acute patient beds are being blocked in Spain

But experiences have varied widely, not only in the different regions but also in health departments, hospitals and local institutions within the same region.

When Paulino Rivero disclosed the Canary Islands’ data on bed blocking, the Health Ministry issued a statement noting that it was working on a plan to integrate health and social care with the aim of offering integral care assistance.

This kind of work is being closely followed by the association of elderly care homes, which has over 50,000 vacancies and has already volunteered to help free up acute beds at hospitals.

“Between 50 and 60 percent of our facilities are adaptable to the needs of these patients,” says Alberto Echevarría, head of the Federation of Dependence Entrepreneurs.

Meanwhile, Roberto continues to wait for a definitive solution. “If all goes well, in 12 months my father will have a definitive spot in a public social care center,” says his daughter — who began doing the paperwork three years ago.

With reporting by María Sosa Troya, Patricia Tubella, Reyes Rincón and Sonia Vizoso.

“Chronically ill patients are more a solution than a problem”


Making home a place to care for the chronically ill, as a way to guarantee the sustainability of the healthcare system. That’s what is needed in Spain according to Rafael Bengoa (born in Caracas, Venezuela, in 1952), who is a former health chief for the Basque Country, and a consultant on health reform for the European Union and the United States. He believes that greater pace of change is needed in order to adapt the health system to real demand.

Question. Is it normal in Spain and the EU to have beds occupied by chronically ill patients?

Answer. Yes, it’s normal. That in itself proves that this is not a problem with patients’ families or with the chronically ill, but rather the care model. Chronically ill patients are more a solution than a problem. They need a very different care model, because the data shows that half of the hospitalizations of chronically ill patients could have been avoided if things were done better before and after. If they are still there, it’s the fault of the model, which doesn’t stop them from being admitted to hospital and doesn’t give them any solutions for when they leave. And there are more and more cases as time goes on.

Q. Will healthcare managers be able to make changes?

A. We still have the time to do it, but we need to start now. All of the parties know that the current care model is incompatible with the amount of illness that is out there. Changes are already being made in the Basque Country and in half of Europe, and they are going to be made in the United States.

Q. In which direction are the changes going?

A. In all of these places, the healthcare reforms have three components: an active patient who is given training so that they make better use of the services available and control their illness better, which generates cost savings of around eight to 21 percent; the integration of patient care, so that this takes place more at the patient’s home and at their local doctor’s surgery, and not so much in hospital; and the promotion of technological advances to help with treatment at home.

Q. These are medium- and long-term measures…

A. Yes, but we can go a lot faster than people think. At the end of the last legislature, they were already starting to see results in the Basque Country, and after three years there are more than 3,000 active patients who have been trained. They rely on the system less, and they have better control of their illness. Once there are 10,000 patients there will be even better results.

Q. If those chronically ill patients end up in hospital, what is the alternative? Create special clinics to treat them?

A. Everyone wants to be at home for the longest amount of time possible. That is our starting point: the home as a care center. But this isn’t the model that is emerging — instead there is a fragmented trajectory. This is because we haven’t started working based on the patients’ needs, but rather based on what those at the top are thinking. Between primary care and seriously ill patients there is a need for a center for the chronically ill. Our obsession, in any case, was home and primary care. That is why we created more health centers.

Q. But many chronically ill patients have social needs. Do we need to start talking about a system that unites social care with healthcare?

A. Patients are constantly tossed between healthcare and social care, and continual patient care lies with both. A single agency to manage both systems is not needed, but what is necessary is a single budget and joint planning. That’s good for both the patients and the economy. There need to be joint evaluations of each case, and a personalized response. In the Basque Country we gave the population a ranking and we could see that five percent of patients accounted for 50 percent of spending. Why not offer them a social and healthcare package? Half of Spain has the structure to do so. It’s something that can be done quickly and that will bring about savings. There are none to be found, however, in co-payment, which is most common in Spain today.

Q. It would seem that the ministry is phasing out those co-payments.

A. There are already four or five regions governed by the Popular Party that are doing what I have suggested. But we all need to pick up the pace. If we don’t, we are going to have to ration [healthcare], offer fewer services, fewer drugs and fewer technologies. The Health Ministry has come up with a plan, but it doesn’t see the strategic nature of chronic illness. You cannot deprive that area of spending and hope that something happens in the meantime. We are losing an entire legislature focusing on co-payment.

Q. Is the crisis an obstacle for this kind of reform?

A. The crisis has been very good for us because the health sector has seen that change is needed. Northern Ireland is already transferring four percent of its budget to primary and home care, and the Basque Country had already started. The unions should support these changes, which demand more flexibility. If not, union resistance will create conditions that will leave the model unchanged, and that will lead to a model of rationing or of privatization, which is not the solution either.

Q. Is the private network benefiting from that public resistance?

A. Yes, indirectly the private network benefits from the lack of change in the public sector, from its need for leadership, energy and speed. Changes need to come in quickly. The private centers also need their own model because if not, they will have higher costs, which they will have to pass on to their customers.

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