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This page created April 2000 by Michael Wynne
Health care is currently structured along
lines of funding. Graeme Samuel in his speech to the world bank has
suggest it be structured in terms of an economic theory. I suggest
that it be structured along the lines of the services provided so
that these can be brought to patients balancing efficiency against
need and service
Marketplace Structure:- In his speech to the World Bank Samuel proposed restructuring the health care marketplace around a set of arms length marketplace "roles"
I am and have been critical of the way the system is structured in Australia because it is not structured for the patients or for the services which the health care is to provide. Samuel plans to compound the problem by restructuring the system to fulfil a hypothetical set of roles congruent with an ideological theory of economics which he supports. A not dissimilar fragmentation exists in the USA.
Something Better:- I would respectfully suggest that it is past time that we confronted this problem of inappropriate structure and restructured our health system along the lines of the services it provides so that these services can be brought to our citizens in the most efficient, most equitable, and most effective way, giving them as much choice as we can. These are Samuel's objectives but the marketplace which he advocates has failed to do so and the USA is an extreme example of this. Samuel's structure is in the service of economic theory and not the health system.
A Fragmented System in Australia:- In Australia we already have a health care delivery system which is fragmented on the basis of who pays rather than the care given. We have Commonwealth (university departments) vs state, public hospitals vs private hospitals, for profit vs not for profit, hospital vs community, metropolitan vs rural. Each of the health care services which actually provides care to patients is finely fragmented across geographic and administrative boundaries. Patients and the care they receive are the meat in the sandwich. This is not only costly but inefficient and wasteful with reduplication of equipment and services.
Even in this system hospital loyalties, rather than cross hospital service loyalties create a competitive situation where each facility and each little group in a hospital strives to provide all of the resources for each discipline. Cross hospital appointments are rare and to function as a specialist each doctor must be able to carry out the full range of services offered by his specialty. If he did not he would lose accreditation by his college. Each is under pressure to demonstrate that this service and its equipment is being used in the hospital where he or she works. In this inefficiency it mirrors the marketplace.
In this fragmented system the full potential for the maintenance of standards, of professional responsibility, of oversight, of research, of digital communication and of teaching is difficult to realise. It is more difficult for any clinical group to organise itself to practice economically and efficiently and to ensure equity in access and in standards. It is difficult to introduce a system of equitable rationing. It is a credit to the staff who work in this system and to the coordinating influence of the professional colleges that it does do well.