In 23 facilities audited by NIK measures were taken to guarantee safety to both the personnel and patients: work organisation was changed, as well as housing and sanitary conditions. They were not always effective, though. Due to architectonic barriers not in all hospitals provided separate transport routes for COVID-19 patients and other patients. The medical staff were not regularly tested for coronavirus and in some facilities scheduled patients were not always tested. As a result, the SARS-Cov-2 infections spread and disturbed the work of hospital wards.
NIK also established that hospital beds available for SARS-CoV-2 patients were not used optimally in the audited period. In one facility not all beds were fully used, even at the time of increased COVID-19 infection rate. It needs to be emphasised that the treatment of patients with other diseases was considerably reduced at that time. According to NIK that resulted in an increased health debt, i.e. the situation where the citizens’ health condition deteriorates due to limited access to healthcare. At the same time, as compared with the average from 2015-2019, an increased number of deaths was reported in the entire period audited by NIK. In 2020, the average was exceeded by over 85 thousand, including about 56.5 thousand for reasons other than COVID-19.
Financial liquidity of the audited hospitals did not change in the pandemic. However, in the audited period most of them did not fully implement contracts signed with the National Health Fund (NFZ) and the value of healthcare provided was down by over 20% as compared with 2019.
The National Health Fund also provided extra benefits for the medical personnel who cared for patients with suspected or confirmed COVID-19 infection. From January 2020 to June 2021, the audited hospitals earmarked the total of about PLN 240 million for that purpose but the principles of granting the so-called COVID benefits were not homogenous. In nearly ¾ of the facilities they were not determined by the time worked with such patients or the number of healthcare services provided. The benefit was also paid to employees who had incidental contacts with SARS-CoV-2 patients.
Already in 2018, during the audit on infections in medical facilities, NIK addressed some recommendations to the then minister of health. According to NIK, the recommendations were to help hospitals prepare for the COVID-19 epidemic and limit the scale of increasing “health debt”. The findings of NIK included missing isolation rooms in some facilities or a shortage of medical personnel, which was non-compliant with the Act on Prevention and Control of Infections and Infectious Diseases in People and Covid-19 Disease.
Work organisation
From January 2020 to June 2021, there were nearly 29 thousand COVID-19 patients in the hospitals audited by NIK. That was a big logistic challenge to provide hospital beds to all of them as it required reorganisation of work in the existing hospital wards as well as some adaptation or modernisation works. As a consequence, individual facilities had from 4 to 186 beds maximum at their disposal, available for patients with suspected or confirmed COVID-19 infection.
Although the management of all the audited hospitals implemented relevant procedures to prevent SARS-CoV-2 transmission, in most of them it was impossible to fully separate transport routes for patients with suspected or confirmed COVID-19 infection and other patients.
Also, regular screening tests for early detection of SARS-CoV-2 infections and epidemic foci were not made among the personnel of the audited hospitals.
Besides, about 20% of patients admitted according to the schedule for other reasons than COVID-19 were not tested for SARS-Cov-2 in the audited period.
In the second quarter of 2020 in the audited hospitals there were shortages of personal protective equipment. In the first half of 2021, the use of surgical masks went up seven times as compared with 2019 and the use of FFP2 and FFP3 half-masks increased by as much as 45 times. The highest use of personal protective equipment was in the fourth quarter of 2020, that is when the COVID-19 infection rate was the highest.
The work organisation of the audited hospitals was also impacted by:
- a significant increase in the costs of personal protective equipment, disinfection and keeping clean,
- the need to provide oxygen in required quantities, also to modernise the oxygen installation,
- the need to work in improved sanitation regime to prevent the occurrence of SARS-CoV-2 epidemic foci among the personnel and patients,
- large number of administrative decisions on arranging beds for COVID-19 patients and a short time to implement related recommendations.
Availability of healthcare
The COVID-19 epidemic quickly showed that the audited hospitals being part of the public healthcare system were not prepared to function in crisis situations. In the facilities audited by NIK some medical services were limited or even temporarily suspended. The main reasons were:
- the existing wards were transformed into COVID wards and hospital beds were provided to patients with suspected or confirmed COVID-19 infection,
- the Minister of Health and the National Health Fund recommended that the scheduled procedures be limited to the required minimum or temporarily suspended,
- the functioning of hospitals’ specific organisational units was limited due to SARS-CoV-2 epidemic foci,
- the absence of medical personnel was growing. In the audited facilities the absence rate (due to sick leave, isolation or quarantine) of persons hired under the employment agreement went up from 5.6% in 2019 to 9.3% in 2020 . Though, the highest absence rate increase was reported in 4Q2020 and reached 13.3%.
For all these reasons, and due to an increasing number of patients who put off scheduled medical appointments or hospital admission dates, the number of persons waiting for healthcare services went up.
The hospitals could not provide patients with the care level from before the epidemic. The value of healthcare provided in those facilities in 2020 was lower by about 21% than in 2019 and from January to May by 23% than in the same period in 2019.
In 2020, as compared with 2019, the biggest drops in healthcare values occurred with patients having the following diseases: of the respiratory system (by 25%), of the muscle and skeletal system (by 22%) and of the circulatory system (by 16%). However, the largest decrease – by about 46% - was related to children’s protective treatment. It needs to be stressed at the same time that even in the periods of low SARS-CoV-2 infection rate, average healthcare values from the same months in previous years were not achieved in the audited hospitals.
Although the needs of patients with other diseases than COVID-19 were not fully met, the capacity of the audited facilities in terms of SARS-CoV-2 treatment was used only in part. The higher number of beds in COVID wards and increased readiness to diagnose and treat patients with suspected and diagnosed infection did not always correspond with the actual demand for healthcare at a given moment, even when the infection rates were the highest.
Financial standing
As a result of hospitals’ involvement in fighting COVID-19 and limited admissions of other patients, contracts with provincial branches of the National Health Fund were not fully performed. In the audited period, the audited facilities provided healthcare service totalling 76.5% of the lump-sum payment for basic hospital care.
In the audited period, in 21 of 23 facilities the value of revenues from the National Health Fund increased. That was the case thanks to contracts on healthcare services related to prevention, counteracting and control of COVID-19 and being ready to provide such services.
That did not significantly impact the hospitals’ financial standing, though. In 2019, 19 facilities generated losses totalling nearly PLN 122 million. In 2020, the losses of 16 hospitals reached about PLN 118.5 million. Reasons included imbalance between medical activity and the cost increase, similar to the revenue increase.
The audited hospitals also received funds from the National Health Fund for COVID benefits for medical personnel who had direct contact with patients with confirmed or suspected SARS-CoV-2 infection.
The benefit payment principles varied across hospitals, though. In 17 of them the COVID benefit amount was determined neither by the time worked with a patient with confirmed or suspected SARS-CoV-2 infection, nor by the number of healthcare services provided. Only in six hospitals the benefit amount was proportional to the personnel’s working time and was determined by the employees’ involvement in the care for patients with confirmed or suspected SARS-CoV-2 infection.
It needs to be highlighted, though, that the non-standardised principles of benefit payments resulted from various interpretations of provisions of contracts the hospitals signed with provincial branches of the National Health Fund. They did not specify precisely the number of services provided or the time spent by the medical personnel with a patient with confirmed or suspected SARS-CoV-2 infection.
NIK recommendations
To the Minister of Health and governors
- to analyse on an ongoing and regular basis the use of beds available for patients with confirmed or suspected SARS-CoV-2 infection to optimise their use and improve access to healthcare for patients with other diseases.
To the hospitals’ management
- to properly classify personnel entitled to the extra benefit in 2020-2021 (1st half), proper settlement of contracts with the National Health Fund concerning the payment of benefits, and to pay the benefits in due amount to entitled persons.
