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No health service provider stands alone. Each is but one component in a system of inter-dependent components; a system which has evolved over centuries and most significantly within the 20th century; and which we can expect will evolve as rapidly in the next.
This text provides a framework for thinking about hospitals, systems of hospitals and other organisations in relation to ourselves, significant factors which shape our needs and demand for intervention. and how we and our society respond.
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Image [1] approximates a modern (Australian) health care system. It illustrates the inter-dependency of basic system components and lines of influence necessary to understanding and planning health care infrastructres, hospitals and other components of the system.
The diagram may read like this: we, (the 'Self') and our environment interact to define our health and symptomatology. While causal factors in our environment and ourselves, indicated in the upper part of the diagram, are largely ungovernable by individuals, some may be eradicated or otherwise moderated1 by co-operative, public or private sector action: the various public infrastructures, disease eradication programs, mass immunisation, settlement planning and design, advertising and other actions to moderate behaviours. Moderated or not, causal interactions are felt by ourselves and may be expressed as a demand on the health care system; and the effectiveness, cost efficiency and economics of the system, indeed its social equity and fairness are ultra-sensiitive to management systems, government policies borne of party political ideologies as oppposed to objective analysis, and also funding system design.
In response to symptoms, we seek advice from a General Medical Practitioner (GP), within our local community, or from an Emergency Physician (EP) embedded in a hospital (H). These are the gateways to health care in Australia.
Subject to party political interference, there may be no charge for our attendance at a public hospital emergency department or for services received in a public sector hospital. Australia's Medicare pays some of the scheduled fee for the services provided by medical and other nominated practitioners. Whether there will be an “out of pocket payment” by the patient, depends on whether the doctor “bulk-bills” Medicare and or charges more than the Medicare scheduled fee. At June 2014 upwards of eighty percent of Australian GPs bulk bill.
The GP or EP may prescribe a treatment regimen and discharge us home or refer us to a Specialist medical Practitioner (SP) working in independent practice or within the hospital, who may also refer us to another specialist, commission investigation and or prescribe a treatment regimen which may be delivered in or out of hospital as either a private or public patient. It is a failure of the Australian system that private patients are treated sooner than public patients.
Following treatment, we may be discharged home, transferred to a rehabilitation or restorative therapy service, (RS). At some point we may be assessed to need continuing care in our own home (HC) or residential care facility (RC). And in reflection of our need there will be specialised facilities for our special needs.
If we suffer an acute episode of mental illness our GP may be refer us to a psychiatrist or clinical psychologist who may be a member of a community based mental health team. If we require hospital care, we may be admitted to the Psychiatric Unit of a general hospital or to a specialist psychiatric hospital. Regrettably, along the way, continuity of care may be broken, because of dysfunctional service-infrastructures.
If we are aged and or suffer, say, Alzheimer's Disease or Korsakov's Syndrome we may be referred to a geriatrician or psycho-geriatrician working cooperatively from purpose designed facilities in a hospital with appropriate investigative capabilities.
If we are a child or adolescent we may be referred to specialists in paediatrics or adolescent medicine working within a specialist children's hospital or from a medical centre located apart from the hospital.
At our discharge from specialist or hospital care, our Primary Care and Mental Health Team may be informed of the reasons for admission, treatment outcomes, prognosis and continuing care requirements. We may be issued with mobility aids and any modifications to our home and other home care services may be initiated to enable us to live independently; moreover we may be 'followed up' by the community team; “may” because there is no certainty.
As well, along the way, information about our condition and outcomes, may be passed to a public health unit who may initiate actions intended to protect the community, to eliminate, moderate or mitigate causes, arising in the environment or the populace at large.
Our health service is designed so that we are admitted to a public hospital only when necessary and then in order of clinical urgency. Privately insured patients may be admitted to a private hospital for needed, or discretionary services more or less at any time of their own choosing.
Generally, public hospitals focus on treating acute, sudden onset episodes of illness or injury, whether arising from a latent or known chronic condition and whether demanding attention immediately or over an extended period Generally, most emergency care is provided by public hospitals. Emergency admissions account for upwards of thirty five percent of all admissions. Few private hospitals provide emergency care. Private hospital patients are often transferred to public hospitals when matters become life threatening or otherwise seriously complicated. Inter-hospital transfers between public hospitals are inherent in a regionalised hospital infrastructure.
Seventy percent of Australia's acute hospital beds are provided in public hospitals operated by State Governments. They consume a large proportion of State expenditures.
Not without reason, politicians consider the health sector the most uncomfortable of ministerial portfolios. Is there another portfolio which so enmeshes human values, political ideals, ideologies, science, technology and specialist knowledge with the quality of life and death?
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In progress @ 24/02/15
1 For better or worse.
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