Mall Medicine solution could be the future of health care
Patients needing one or more health services should have a one-stop-shop solution and 24-hour access
The current health-care delivery problem will not be solved by an infusion of more money nor by multiple minor changes. It must be approached with a broad stroke that radically alters the health-care physical and organizational environment in which this delivery system operates. There also must be a major change in the operational organization of doctors and other allied health-care workers in order to provide ambulatory primary and secondary care 24 hours a day.
When I started practice 64 years ago in Hamilton, doctors were solo practitioners with maybe the odd partnership. The only exception was the McGregor Clinic consisting of a group of specialists. There was the medical arts building where there were only a few family doctors, the rest being specialists in solo practice. Nearly all the doctors in Hamilton were on call all the time except if they signed out, on a one-to-one basis. There were the two hospitals in which there were no practising specialist’s office.
Compare this to today. Nearly all family practitioners are either solo or in groups of three to seven. There are family health groups, either together in small groups or in separate locations. They are available eight hours per day, five days a week except for some varied on-call coverage the rest of the time. Specialists are scattered around town, some still in the medical arts building and 25 Charlton, but none are in a real group practice. The McGregor clinic is gone. The full-time medical faculty specialty practices are scattered throughout the hospitals. Their site of accessibility is varied geographically throughout the city. The rest of the community ambulatory specialist consultants are available five days per week, eight hours per day on various sites. Selective specialists are on call 24 hours per day for hospital consultations and urgent care. There are diagnostic services outside the hospitals but, again, available only eight hours daily five days per week.
How different is this really than 64 years ago, except there was more availability then of primary-care and general specialists? Today, medicine is more complex with so many diagnostic tools, complicated therapies as well as so many different specialties involved. It should be obvious that this requires even more of a co-ordinated effort. There are more chronic illnesses in an older population that has tipped the whole system into a near impossible task for the current health-delivery system. The current health-delivery system is at a cost that society can hardly pay now and will only get more costly, as well as more confusing, to both the patients and the doctors.
Even if patients are seen by their family practitioner in a timely fashion, for all other elective ambulatory services they must go to different sites for consultations, diagnostic tests, therapy and more. This occurs with delays and with little, if any, co-ordination of patients’ time or ease of accessibility. The elective ambulatory services are available only eight hours per day, five days per week. The rest of the time the majority of patients who feel they have an urgent problem have three alternatives: phone an 800 number and speak to a nurse, go to one of the two urgent-care centres or go to the hospital emergency department. None of these are time efficient and most important, optimally effective. The time made available for patient care is determined by the availability of doctors equally as it is determined by the availability of the other health services.
The solution in my mind is to develop a one-stop approach for all ambulatory care with hospitals confined to their designated role. Hospitals should only be used for those patients needing their specific facilities and services. Hospitals should be used for only the urgent care that requires their specific expertise. There should be what I call a Mall Medicine solution. This should start with a planned trial project to allow a patient to go to one place to receive their primary care, urgent care, secondary consultations, diagnostic tests, mental health care, rehabilitation and any other ambulatory services. It is most important that it provide 24 hour urgent care. Another role for such a centre is to be the base of operation for outreach health care in the community, especially for the elderly and those with complex chronic health problems. In addition, it could refine the application of E-medicine to be more effectively utilized in patient care. This system should be readily accessible to patients so that so they do not have to wander about, often lost, in the desert of our current scattered, time-restrained system of health care. Once one such project is developed then the system could be replicated as a work in progress, fine tuning it as time goes on, to become a universally adopted health-care system.
This system would provide the ideal ambulatory environment in which to train doctors, nurses, social workers and all other health-care workers, leaving the hospitals primarily for specific tertiary specialty training.
If this works, everyone will win: the patient with availability and accessibility; the doctors with better facilities, educational possibilities, cross pollination with specialists and a chance to learn and grow. Most importantly, it would result in timely, efficient and effective care. It would allow the hospital to effectively fulfil its role. This could be made cost-effective with less duplication of services and have the ability to measure outcomes more accurately.
The key here is the leadership of doctors. For this model to work they must provide care when needed or closely supervise care that is delegated. Thus the doctors must provide the manpower to adequately provide coverage 24 hour hours per day, seven days per week. This can only occur in an environment like I have described.