Is it time to Consider Decentralisation of Hospitals?

Max Weber, the German sociologist said, “The only alternative to bureaucracy is a return to small- scale organization.”

But before the term decentralisation starts to bring out negative emotions, let’s first understand the real meaning of this word. It is mainly an idea which states that smaller organizations have the ability to properly structure themselves and are inherently more agile than the larger organizations.

It is noted that over a period of time, when the organization grows, the bureaucracy grows as well.

The European healthcare system presents a fair idea of how decentralisation has worked in their favor. For instance, in Norway, most of the healthcare sector is public and groups of public hospitals are organized as separate legal entities with separate boards. These groups are known as local health enterprises which are further owned by four regions. These hospitals have complete control over the budgeting, staffing and management without too much interference from the regions.

Denmark is another model that has successfully utilized decentralised model of providing healthcare. The focus is on delivering as many services as possible through primary healthcare, municipalities, health centers and outpatient clinics and as little as possible from their hospitals. The future role of the hospital is thought of as the place where one goes when someone needs highly specialized healthcare services. All other kinds of problems are therefore dealt through primary care by empowering the GPs, municipalities and clinics.

Of course, this cannot be completely replicated in countries like India where there is a hybrid system of public and private healthcare. But definitely, some of the non-critical functions can easily move out of the hospitals.

I would also like to emphasize upon the need for separate infectious disease and non-infectious disease care facilities. There is already enough evidence of high rates of hospital acquired infection (HAI) globally. Some of the most common infections that the patients’ contract in the ICU includes pneumonia, bloodstream infection and urinary tract infection (UTI). Patients undergoing surgeries with comorbidities are all high-risk patients.

At the same time, the doctor to patient ratio in India is very low (1:1500). The nurse to patient ratio for India is only 1:483, i.e. 2.1 nurses per 1000 population. With this ratio, dealing with regular patient load is a challenge and, in this scenario, dealing with the pandemic is the healthcare system’s nightmare.

This pandemic has proved that if there is only one place for treatment of all kinds of diseases, every other disease is ignored and the entire focus of the hospital and the staff is in dealing with the infectious disease. Thus, putting enormous pressure on the frontline workers.

World over, separate quarantine centres have been established outside the hospitals. These facilities were built primarily because the hospitals ran out of capacity. But they also helped in mitigating the risk to other patients and caregivers. Infectious diseases pose a threat not only to the patient and his family but also the frontline workers who are involved in servicing them.

Some of the well documented advantages of the decentralisation include:

• Quick decision making where the decisions are mostly focused around better customer service.
• Easier and faster implementation of any change (both at policy and practice level)
• Better and higher overall motivation of the working staff than those working for larger organizations.
• Freeing up the time of the specialists who are already neck deep in work, for more critical patients.
• Faster and seamless response to any situation especially in times like COVID 19
• More robust and simpler ways of making comparison of different units. Thereby helping in improving the outcomes. One can easily create a Six Sigma unit within the hospitals.
• Reduced direct and indirect cost to patients.

Now one can debate that hospitals like Fortis, Apollo and some more have already done this by establishing separate units like Fortis La Femme, Apollo Sugar Clinics, Apollo Cradle and more. There are also several polyclinics where some of the non-critical functions exist.

But the point here is that if this is done by few and they have been successful, maybe it’s time to make a policy level change and move all non-critical functions out of the hospitals. Maybe it’s time to empower the GPs more and let them be the gatekeepers for the specialists. Maybe, it’s time to start promoting telehealth and encouraging care and rehabilitation at home.

Various organizations around the world have benefitted from decentralisation and creating a hub-and-spoke model for successfully running large organizations. Maybe it’s time to think about this for the hospital sector as well.

(Molshree Pandey is a biotechnologist and management graduate with over 15 years of experience in consulting for healthcare and lifescience companies. She is the Country Head and a founding member of the Innovation Centre, Denmark. She is also a regular contributor of knowledge pieces various local and internation platforms.)