Hungarian healthcare: Emergency service

One hears far too many horror stories about patients in need of urgent care who are being bounced from hospital to hospital. The staff in one hospital claims that for one reason or another they can't handle the case and recommends that the patient be transferred to another institution. To those of us who are not familiar with the workings of Hungarian hospitals these trips from hospital to hospital and often from city to city seem quite mysterious. The latest case, involving a 57-year-old man complaining about a bloody stool who a few hours later lost consciousness en route to a third hospital and subsequently died, prompted me to study the matter a bit.

Let's start with some facts and figures. There are 51 hospitals in Budapest with a population of 1.7 million (2009). In New York City (population 8 million) there are just over 70. How is that possible? As far as I can see, most of the Budapest facilities are specialty hospitals. I found several children's hospitals and hospitals that specialize in cardiology, or internal medicine, or surgery. Of course, there are a few general hospitals as well. But even then, it can often happen that the hospital has several buildings located in different parts of the city. This system to my mind is anything but economical, efficient, or medically satisfactory. After an examination in one hospital, the doctors might come to the conclusion that the case needs further tests that are available only in some other hospital. Then, depending on the condition of the patient, an ambulance might have to transport him, and we know that this is not an inexpensive undertaking. In a more centralized hospital it would be a simple matter of wheeling him to another floor or another wing of the same building.

But that's not all. There are the "anomalies" of the emergency service. The Hungarian system is based on the old decentralized German system. First of all, not all hospitals have an ER, and those that do offer only certain kinds of emergency treatment on certain days. Cases that need surgical intervention on Sunday, let's say, must go to X hospital, while with some other ailment the patient must go to Y hospital where there is a team of doctors specializing in internal medicine. There is a central coordinator who organizes all this. But, of course, it's virtually impossible to know in advance just what is wrong with the patient. So the patient arrives at hospital Y. The internal medicine team at hospital Y decides after an examination that the patient should really be at hospital X, which specializes in surgery. So the patient is transported by ambulance to hospital X. But what if the team at hospital X decides that the patient really doesn't need surgery? Or that he needs surgery, but perhaps cardiac surgery that is not offered at hospital X? It's easy to see that this old method is flawed.

What the Hungarians should do is to introduce the so-called Anglo-Saxon method that offers "complete service" at one place--"one-stop shopping." This is not just my view, which might be attributed to my Anglo-Saxon bias. I heard the director of one of the hospitals involved in the latest case state that the Hungarians should adopt this "new" system.That is something of a conceptual breakthrough in Hungary. He claims, however, that the introduction of comprehensive emergency service would require additional money, not available to Hungarian healthcare at the moment. My feeling is that a total reorganization of the whole system of hospitals could save a great deal of money. Hungarian critics of the system claim that both "poverty and waste" are present in the Hungarian system.

Let's return to our 57-year-old man whose case vividly illustrates the problems with the system. A family doctor was called out who, based on the patient's bloody stool, decided that the man was suffering from gastric hemorrhaging. The doctor gave him a piece of paper that allowed him to go to the district hospital, which happened to be the Sándor Péterfy Street Hospital. The doctor on duty decided that the man must go to a surgical unit, but on that day there was no surgical emergency service in Péterfy. So he was sent over to the Szent István Hospital where three surgeons were on duty. The surgeon who examined him decided that after all the man's problem was not of surgical nature. So he ordered him sent back to Péterfy, but not by ambulance because the patient's condition didn't seem to warrant immediate attention. The patient was told that he might have to wait a few hours until a medically equipped car, not an ambulance, could pick him up. The relatives accompanying the man obviously decided that they had had enough and without saying a word to the medical team put the man into their car. Instead of going back to Péterfy, they decided to go the Szent Margit Hospital where they knew a doctor. On the way there the man lost consciousness and by the time an ambulance came to his rescue the man was practically dead. He died the next day in Péterfy.

The doctor at Szent István was suspended, the ministry ordered an investigation, and the staff of Szent István is very upset because they feel that the media handled the case unfairly and inaccurately. Today the result of the autopsy revealed that the man's death had nothing do with to gastric hemorrhaging. He died of an aneurism.

Most likely the man's death was inevitable, but the story is still not pretty. I believe that the doctor at Szent István followed the rules and regulations when he sent the patient back to Péterfy, but I can also understand the relatives who considered going back to the same place where they started worse than a waste of time.

Healthcare reform was aborted a year and a half ago, money today is even scarcer than then, and problems are on the rise. And on top of everything else the directors of hospitals, all 170 of them, are threatening a hunger strike if the government doesn't give them an additional 23 billion forints from the central budget. These same hospital directors did everything in their power to prevent the implementation of any kind of change. I find the whole thing distasteful.

Comments

[Sandor]

You forgot to mention the amount of gratuities the patients paid to the doctors this year and which was something like 300 billion forints, if memory serves correctly.
This money, tax free and fully left with the doctors, was a multiple of the sum necessary to buy a gold-plated and jewel-encrusted health care system.
In my opinion the government must not pay one red penny to the hospitals, because they were opposing reform tooth and nail, and because they are rotten corrupt to the core. Every money they get is squandered.

[NWO]

There are so many fundamental problems with the healthcare system, that in this forum it is impossible to list them all. On the main point you were discussing, there is at least issue worth raising. One of the primary obstacles to changing the hospital system is the influence of the senior doctors managing and controlling the hospitals. These Drs have a vested interest (in terms of both power and remuneration) in resisting any change to the current system. As a result of this outdated system and the entrenched power of the head doctors, many of the most talented doctors trained in Hungary in recent years are working outside of the country.

[Hank]

Yes, these senior doctors/hospital directors are very much responsible for blocking reforms cause they protect their vested interests.
Yes, gratuity money is a major problem though it is not 300 billion forints a year but more to the tune of 75 billion (theoretically still enough to pay for the requested extra).
But if the sector itself is not capable of reform, an outside force (government/politics) has to enforce reform on it. We all know who was responsible for the referendum which caused the former government to fail.
So now either the healt care sector has to reform itself (forget it) or the new government will have to force them to (forget it).
I'm afraid Hungarian health care will have to collapse much further before anyone will start to finally do something drastically. Expect more people dying along the way.

[Sandor]

I should also mention the fundamental misconception, evident even in the original article, as it is in the entire discourse about this subject, that the number of hospitals is actually irrelevant. It is the number of beds that really matters and the number of nurses.
The "rock" on which the health care really rests is the corps of nurses.
Maintaining the nineteenth century system of hospitals is simply madness. It is impossible to squeeze a fully operational, all round hospital into the small buildings scattered around the country. If New York has only a few hospitals, but complete with all specialities, that is because they are hulking giants with sufficient room and infrastructure. None of that is really available in Hungary.

[Eva S. Balogh]

Sandor: "I should also mention the fundamental misconception, evident even in the original article, as it is in the entire discourse about this subject, that the number of hospitals is actually irrelevant."

The main thrust of my argument wasn't really the question of number of beds per 1,000 population but instead the fragmentation of the hospital network. But, for your information, in Budapest there are 13.5 while in New York City, 4.5 beds/1,000.

[David]

When I was working in Hungary I had to go to the Doctor due to a persistent cough. They were able to see me the same day, in the evening outside work hours, and the pharmacy was open late so I could the required medicines. In the UK with a similar complaint it would mean a wait of about a week for an appointment, highly only recently available outside work hours.

Hungary does not seem to have the UK problem of long (1 year plus) waiting lists for many minor and non life-threatening conditions.

The Hungarian system may be a bit threadbare in some places, but it is still pretty good.

[kata]

Just a couple of thoughts about the lack of health care reform in Hungary and that it is not necessarily the fault of Hungarians as consumers of health care and that of the medical establishment.

“Hungarian critics of the system claim that both "poverty and waste" are present in the Hungarian system.”

Yes, I am sure that there is waste in the Hungarian system. However, I am more worried about the even larger waste and abuse of money in the governmental and political sectors of the Hungarian public sphere. How much of state property and public money has been wasted by going into private ownership into individual pockets and outside the country. How much money disappeared in private hands due to corruption (just to mention some most recent ones: Hungarian Post, Budapest Commute Company (BKV), Hungarian Rail Company (MAV) , Hungarian Motorway (Autopalya) etc., etc.) Much of this waste could as well have been invested into the reform of the health care system. I am also worried about the poverty element. Since the Hungarian health care system is not able to reform itself from within, because of lack of capital, it does, indeed, need governmental help. I never thought that the introduction of “visit fees” was a very good idea. Firstly because, if corruption is so prevalent in other spheres, what’s the guarantee… Secondly, this system just pushed those who were already disadvantaged members of society even into more disadvantageous situation. (Some ill-stricken Hungarians and many pensioners now cannot afford to buy their medication or they would need to spend their entire income/pension on the prescriptions.)

Why is the Hungarian government reluctant to allocate funding to such an important cause as the heath care of the country. Even the most ardent opponents of Tony Blair would admit that he had pumped a lot of money into NHS in order to build it up to its current state. And as most Hungarians ask today, what doesn’t the government allocate some of the IMF money to prop up health care and why has Hungary signed to lend 60 million EU to help building a hospital in Vietnam? (the job opportunity that it might incur may not be a sufficient answer.)
These are also questions that one needs to ask when thinking about the reform of the Hungarian health care system which is absolutely needed but not to the FURTHER disadvantage of people but for their benefit.

As for the non-cooperation of senior doctors/staff, there is nothing I hate more than feudalistic/autocratic systems, however, I think, that if Hungarian doctors were financially acknowledged proportionally (in current Hungarian pay rate context) as well as their Anglo-Saxon colleagues they would not resist structural change. Why would they?

[Sandor]

About that loan to Viet Nam.
When a country, any country extends a loan for a certain project to a developing country, the conditions of the loan are, more often than not, that the loan be spent in the donor country. What happens then is that the borrower, in this case Viet Nam, gets 60 million EU worth of equipment, (possibly those removed and stored after the hospital closures last year), and some personal help in training, set-up, etc. for which Viet Nam will pay later with other goods, or cash. So, in fact the cash outlay for this loan is minimal and everybody benefits from it.
The curses of the opposition are heavily misplaced in this case, because Hungary by opening up this market, is opening up also the prospects of future large health care business for the Hungarian producers and possibly "locking in" for itself the Viet Nam market.

[Mark]

Kata: "Even the most ardent opponents of Tony Blair would admit that he had pumped a lot of money into NHS in order to build it up to its current state."

You will note from David's comment above that all is not well with the NHS (while I don't recognize his problems visiting doctors - as I can always see mine on the day I call them - the waiting times for non-life threatening operations are real, and a serious problem for many people). What is more the increase in funding since 2002 has been accompanied by a significant fall in the service's productivity - thus a large part of the increased investment has been wasted. This is widely recognized to be a result of the lack of reform, which has left top-down bureaucratic structures in place, rather than creating structures in which the money followed the patient. While under-investment is a serious problem in Hungary, as it was in the UK in the 1980s, it is hard to escape the conclusion based on the UK's experience that without some fairly serious reform (which the government in Hungary made a start on in 2006) extra investment will not yield any measurable improvement for patients. And furthermore you have to remember that the UK is an immeasurably richer society with a larger tax base, and one where the demographic and public health pressures are less.

[Kata]

I think most people would agree with the fact that reform is needed. However, the question still remains what would be the best way of reform so that the entire society benefits from it. (I do not think that any reform would be suitable in which people have to die because they cannot afford to pay for their medical care or their prescribed medicine.)

If the leadership i.e. the political elite (left, right and centre ) was not so discredited by corruption perhaps the people of Hungary would also be more willing to listen and give the benefit of doubt to them.

But this not the case. There is a vacuum of credible leadership in Hungary.

(Really just whispering and in parenthesis. What if those members of the political elite who have benefited disproportionately from the accumulated wealth of the Hungarian State since 1989, said, OK ,we’re going to put back those illegitimate acquisitions into the national treasury with the aim of building a better health care system for our county. Maybe that would be a great moral incentive and act as a booster for people to trust and support reforms.)

As for the for the British NHS. Yes, there is waste in there as well. But there is a lot that speaks for it. People still feel protected. Not only British people, but millions of immigrants to the country are treated equally well. And then there are the pensioners who are entitled to free medication after the age of 65. Experiences about waiting lists differ. Some need to wait longer, some don’t.

Addressing the remark, that the UK health care is much better endowed financially. It’s certainly the case. But it was not me who wrote the leading/topic article posing the Anglo-Saxon system as a desirable goal for Hungary. I can only hope that the author did not suggest the American health care system as a model to follow.

[Mark]

Kata: "I think most people would agree with the fact that reform is needed. However, the question still remains what would be the best way of reform so that the entire society benefits from it. (I do not think that any reform would be suitable in which people have to die because they cannot afford to pay for their medical care or their prescribed medicine.)"

I don't think anyone disagrees with this (and none of the parliamentary parties in Hungary do either). The question is how one does it.

I reacted somewhat because I'm familiar with both the health reform debates in the UK and Hungary, and I've received medical treatment in both systems. As a left-winger I believe in principle that everyone should have access to the best quality health care on the basis of need, and the state has a duty to guarantee this. In both countries this has been confused with a means of doing this - providing a state service free of charge at the point of delivery - that has been elevated into a dogma, and there is no space for a rationale discussion of how best health care can be provided.

We know that the UK's 1945 Labour government created the NHS as a means of providing access to basic health care, to fulfill its manifesto committments in circumstances in which - after the end of the Second World War - the British state was bankrupt. We also know from the cabinet discussions that eventually resulted in the introduction of prescription charges that the Labour Prime Minister who oversaw the creation of the NHS, Clement Atlee, favoured user charges (like the Hungarian
vizitdíj)in order to "prevent abuse" and thus allow the better management of demand.

[Alexander Matolcsy MD FACEP]

I had the opportunity to read most of your comments about Hungarian Health Care system and its problems, also regarding emergency medicine. Some of your observations are fundamentaly correct, some are not. I had the opportunity to participate in the development emergency medicine in hungary with various Amarican academic institutions. In the United States we have our own problems with health care and emergency care, they are not the same as in Hungary but the important thing is to move forward. In the US if you leave an emergency department " left without being seen" the department is not responsible for your outcome. The same is in Hungary, if you walk out

Alexander Matolcsy MD FACEP
Ambassador of the American College of Emergency Physicians to Hungary

[Slewy]

Hello!

I don't know what is this site but I've noticed that there are so many Hungarian people. I live in Budapest and I would have liked to find a foreign site which deals with our Healthcare system. Unfortunately this is an actual thing in my life because my grandmother has serious problems with her health. I agree with this article. Our medical treatment is far from reassuring. By the way if you knew a site that contains criticism or information about this topic I would be very pleased if you could send these links for me.

Thank you in advance!

[hospital security assessment]

Thank you for keeping us informed.