WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANT~
REGIONAL OFFICE FOl\ THE WESTEI\N PACIFIC BUREAU UGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Twenty-fourth session Wellington 28 August - 5 September 1973
TECHNICAL DISCUSSIONS WPR/RC24/TDl 15 June lfJ73 ORIGINAL: ENGLISH
THE LIMITATIONS OF THE HOSPITAL1AS THE CENTRE OF MEDICAL SERVICES by
C.W. Dixon M.D •• F.R.A.C.P •• D.P.H. Professor of Preventive and Social Medicine University of Otago Medical School nmedin. New Zealand
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Background document for reference use at the Technical Discussions on "The Role of the Hospital in the Community and the Financing of Hospital-Based Medical Care".
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WPRjRC24/l'Dl page 1
1. Medioal oare was originally provided in the oommunity by the family, the wise man of the village, the apotheoary, and then the dootor or general praotitioner. Medical eduoation a hundred and fifty years ago was based on apprenticeship to a community doctor. 2. The hospital provided a place for these same doctors to treat patients who required nursing oare or could otherwise not be treated at home. The ability to do without hospital admission has been demonstrated by the complex surgery which has been done in the homes of the wealthy and the nobility until quite recent times.
3. With the oonsiderable emphasis on the spectacular, and particularly the life-saVing role of modern surgery, even in developing countries with a very small number of doctors, it was logioal to place the doctor in hospital even if he was on his own, so that such treatment oould be given. The vast mass of other sickness of much greater socioeoonomic importance was untreated by doctors and preventive measures were left mainly in the hands of auxiliaries. 4. As the number of dootors increased, administrators were torn between deploying them in impossibly large districts or of withdrawing them to hospital bases to allow more hospitaltype medical oare to be provided. With improvement in transport by air and by better roads, the argument was strengthened, and when the hospital was situated in a major town there would be pressure from the more eduoated oitizens for sophisticated speoialty services, all requiring more and more doctors.
5. In developed countries the hospital has for fifty years been a prestige symbol in the provision of medical care, so much so that in many countries general practioe has been the inferior service, not attractive to medioal students, and even in oountries where doctors had access to treat their own patients in hospital, hospital care has increased in utilization as well as total cost, as it paid the doctor to treat his patient in hospital rather than at home. In developed countries muoh more than half the medical profession might be said to practioe largely related to hospital provision, and in some speoialty branch, and in some countries only a small proportion of dootors can be said to be able general practitioners.
WPR/RC24/TDI page 2
6. WHO has given strong support to the hospital being made the centre ifor medical services, and in developing oountries with a severe shiortage of doctors, this is the best arrangement, but it soon devellops so that a disproportionate amount of health service finance is spent on hospital oare. With a rise in the standard of living of the population there is further rapid escalation of the cost of running hospitals, mainly non-dootor labour. In some countries the high costs and the reluctance to increase the wages of nurses and others, means that hospital beds are empty because of the lack of supporting staff. A further problem in developed countries is the more efficient use of hospital beds if good general praotitioner and supporting services are available, allowing the patient to be in hospital for a very short time. This rapid turnover of patients further emphasizes the brief episodic nature of hospital care in the life of the ordinary person, and the greater importance from the sooio-eoonomio point of view of good oommunity medioal oare.
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8. Whereas there has been some thought towards making hospitals the repository of patients records, often these beoome a series of unrelated incidents in the patient's life, whereas they are nearly always part of an epidemiologioal oontinuum if we take the trouble to examine a patient's oomplete medical history in this light. 9. In developing oountries a health oentre is often a primary care aid-post without a dootor, in some it has a doctor who provides primary medical oare with assistanoe from others, whilst in some countries the health oentre is mainly, if not exolusively, oonoerned with preventive services, maternity and ohild welfare, eto. In developed oountries the need for a different type of health centre is inoreasingly apparent, with dootors, nurses and sooial workers working as a team, and with good faoilitiesfor diagnosis and treatment, inoluding laboratory and X-ray facll:1,ties, unless a suitable hospital is not contiguous with the health centre. With the development of suitable reoord systems, the health centres serving a town oould be the repository for the reoords of all persons living in the town, and inolude the hospital records. When a patient goes to hospital the whole of the patient's notes would go to the ward whenever he is admitted. The fact that a hospital serving say, a hundred thousand people, would have to deal with possibly ten health oentres at the most, rather than fifty individual doctors, eaoh with quite different systems of maintaining reoords, makes the arrangement practioable. Modern communications systems would also allow the preparation of patients for admission, advanced warning of booking, and it is possible to develop other prooedures dependent on good two-way oommunication
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page 3
between the hospital and health oentre, which would result in considerable saving in wasted beds, wasted surgeons time, operating theatre bookings, delay in discharging patients. 10. The development of a regional health authority whose function is to satisfy itself that all necessary medical services within a geographical area, are provided by someone not necessarily by the authority itself, although it may be the major provider of hospital care, is one attempt to produce coordination of all types of medical service. This authority would be advised by a medical services committee with strong representation from the senior doctors from the health centres of the area. In representing the initiator of hospital care, as well as the main provider of after-oare, having closer contact with oonsumers, the doctors from the health centres should be in the best position to give advice on how hospital services should be organised of a quality and quantity to suit the pattern of medical care provided by the health oentre. 11. In other words, the peripheral, continuous, relatively cheap component of medical care of major socioeconomic importance, the health centre, should mainly determine the type and extent of the central episodic, very expensive minor socio-economic component of medical care located in the hospital.
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