A Health system can be defined as a group of people whose primary focus is to improve the health or wellbeing of others (WHO, 2005). These entities could include organizations such as hospitals and other health care services that respond to the needs of the population. This essay will focus on the three levels of care: Primary, Secondary and Tertiary and explore how patients move through these three levels of health care in New Zealand (NZ), the United Kingdom (UK) and the United States (US). The similarities and differences between these systems will be highlighted and the accessibility of these providers will be discussed.
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There are three different levels of care in terms of Health Systems, each addressing the necessities of the patient and are organized into Primary, Secondary and Tertiary Care (Bodenheimer & Grumbach, 2009). Primary care is usually the first point of contact for many individuals and focuses on ambulatory care such as general practitioners (GP’s), midwives and pharmacists. Healthcare at this level tends to be family orientated and situated around communities, treating ordinary, every day health problems (Alberta Physician Link, n.d.). The Secondary care level usually involves much more specialized services and is generally hospital based; examples include specialized physicians like pediatrics and obstetrics (Bodenheimer & Grumbach, 2009). Tertiary care typically involves specialist physicians such as cardiac surgeons and immunologists. Care at this level comprises of the treatment of uncommon and complicated diseases (Bodenheimer & Grumbach, 2009). The margin between secondary and tertiary health care is difficult to distinguish between as enhancements in modern day technology means that surgeries that are associated with tertiary level is being introduced to local hospitals (French, Old, & Healy, 2001).
Patient flow through the three levels of Primary, Secondary and Tertiary care differs from country to country and is dependent on the country’s focus and organization. Each country operates differently in order to respond to the needs of the population. Patient flow in most cases is a stepwise process and enables efficiency in Health care systems.
In New Zealand, individuals who have health problems will go directly to their GP as their first contact (French et al., 2001). The reason for this is, unless it’s an accidental and emergency situation, New Zealanders’ can only gain access to secondary and tertiary services by referrals from their GP’s. GP’s can be described as ‘gate keepers’ who hold the key to higher levels of health care (French et al., 2001). Only by obtaining this key – in this case a referral, will patients in NZ be able to gain access to secondary and tertiary care. The same situation also applies to private health sectors (French et al., 2001). If further diagnosis is required after seeing the GP, the patient will be referred to a specialist at a public hospital who will be the sole decision maker in deciding the urgency of the situation. If specialized assistance is required, the patient and their GP will be notified within ten days and will have an appointment within six months (Cumming et al., 2013). GP’s taking on the role as gate keepers will lead to the development of a strong patient-caregiver relationship, which eventually leads to better health outcomes (Bodenheimer & Grumbach, 2009).
In the United Kingdom, the British National Health Service (NHS) provides health care. The GPs here also take on the role of gatekeepers and apart from treating every day problems; they also provide prevention services such as immunization to prevent diseases and vaccinations (Boyle, 2011). Similar to New Zealand, patients are unable to gain access to secondary services unless they have a referral from their general practitioners (Bodenheimer & Grumbach, 2009). This system differs from New Zealand in that a referral from a GP to access health care at the tertiary level is quite unusual and is usually attained by a referral from the secondary care level (Wheeler & Grice, 2000). The exceptions to these regulations are accidental and emergency situations, for example, a trip to the Accidental and emergency department (A&E) would not require a referral.
The US health system focuses more on care at the tertiary level. This health system differs from NZ and UK in that patients are able to access secondary and tertiary levels of care without a referral (Bodenheimer & Grumbach, 2009). In the US, patient flow is not as efficient and it has become customary for individuals to approach any doctor of their choice depending on their health problems (Bodenheimer & Grumbach, 2009). The numerous roles specialists and doctors have to undertake accentuate the huge gap in primary care. In NZ and the UK where physicians specialize in providing health care at the secondary level, tertiary physicians in the US have to provide health care at both the primary and secondary level in order to make up for the lack of primary care providers (Bodenheimer & Grumbach, 2009).
Access to health care is how obtainable medical care is. There are numerous barriers to access and these include factors such as cost, transport and locations of hospitals relative to where individuals live. Each country differs in the way they attack certain barriers.
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The US health system focuses more on the concept of the dispersed model in terms of organization and is more orientated towards tertiary care (Bodenheimer & Grumbach, 2009). Health insurance is a major factor that influences individual’s access to healthcare. Individuals in the US have employers who aid in the costs of health insurance. However, individuals who have employers that do not cover health insurance, have to figure out their own way to access health care (Bodenheimer & Grumbach, 2009). More often than not, it is these individuals who do not fit the criteria for public health insurance and do not have the means to obtain private health insurance due to expensive premiums (Bodenheimer & Grumbach, 2009). The number of uninsured people has been increasing and countless employers have responded to the ever-growing costs of health insurance by no longer providing it for their employees. Health insurance in the US poses as the biggest financial barrier towards access and Bodenheimer and Grumbach accentuates this point. Their findings reveal that those who are not insured receive less care, resulting in bad health consequences. The two main public health insurance companies in the US are Medicare and Medicaid. Medicaid’s target audience is for citizens aged 65+ and in low-income families while Medicare’s targets disabled individuals and residents who are 65+, under 65 year olds are funded by private insurance (The Commonwealth Fund, 2012). However, many physicians do not accept people with Medicaid insurance as this means they receive less payment. Compared to the individuals who are uninsured, those who are insured with Medicaid have a much more stable source of health care and access to other services. However, in contrast to the others who are privately insured, they are more likely to have difficulties when pursuing medical care and other prescriptions (Bodenheimer & Grumbach, 2009). Numerous residents are underinsured and uninsured (The Commonwealth Fund, 2012) resulting in less people obtaining access to medical care. People are entitled to refer themselves to any level of health care depending on their situation, resulting in a large out of pocket fee if they were uninsured. However, access to health care is incredibly beneficial for the well off individuals who are able to afford private insurance. The US health system primary focus on the tertiary level impacts access as it allows entry into any level of care depending on the patient’s choice and this is incredibly advantageous for those who are well off, but poses as a disadvantage for the poor and those who cannot afford health insurance.
In NZ, the health system focuses more on the regionalized model in terms of organization and is orientated towards primary health care. The Government along with the District Health Boards (DHB) and Primary Healthcare Organizations (PHO) plays a huge role in delivering health care to individuals in NZ (Gauld, 2012). There are two types of PHOs established, interim and access (Malcolm, 2004). Access PHOs subsidies 60-70% of GP costs for those in disadvantaged areas, whereas Interim PHOs subsidies 30-40% of GP costs for those who are in less disadvantaged areas (Malcolm, 2004). This will enable those who live in underprivileged areas to gain access to health care, without worrying about costs. Most hospital fees are free of charge with some additional expenses depending on different situations (Cumming et al., 2013), the government also subsidizes visits to the GP. This means that those who struggle financially will be more likely to access primary health care, enabling better health outcomes, especially because a referral is needed in order to access secondary and tertiary levels of care. Individuals are also able to obtain private health insurance, allowing them to receive a private appointment with a surgical consultant before individuals who are noninsured, resulting in a reduction in wait times for surgery (Cumming et al., 2013). However, there could be a limit in choices of private providers as they are mainly situated in the main centers, limiting access for those in rural areas (Cumming et al., 2013). Large distances and small numbers of care providers make it difficult for populations in rural areas in NZ to access health care (Cumming et al., 2013). This poses as a significant barrier that limits access as those who live a great distance away have a limited amount of options in terms of health care. The distribution of health care services and physicians in rural areas is smaller as this life style is undesirable, reducing rural populations’ access to health care (Cumming et al., 2013). Access in NZ is beneficial as hospitals are situated in good geographic locations as studies reveal that 90% of individuals are able to reach a district hospital within an hour (Cumming et al., 2013). NZ’s focus on the primary health care level impacts access as it allows individuals whom require specialized care to gain access by referral from a GP. Compared to the US, access to health care in NZ is favorable for those who live in good geographical locations but poses as a disadvantage for those in rural areas.
In the UK, the health system is similar to NZ in that its health system is structured like the regionalized Dawson model and orientated towards primary health care (Bodenheimer & Grumbach, 2009). The British National Health Service (NHS) provides primary care and hospital services (Boyle, 2011). Most primary health care is free and is covered by the NHS, although there are some out of pocket payments that are not covered (Boyle, 2011). Free primary health care would maximize access, as those who struggle financially will still be able to seek treatment without concerns of payment. Boyle’s research also reveals that there has been many unnecessary trips to the A&E were not considered as crucial, possible reasoning for this could be due to their inability to obtain primary health care. Waiting times in the UK poses as a barricade to health care, with some patients waiting up to 18 months for surgeries, however, the average waiting time has now been reduced to 18 weeks (Boyle, 2011). Long waiting times reduces access which means that less people will be able to receive the care that they need in the time that they require it. These wait times could’ve instigated numerous avoidable A&E trips that could’ve been solved by the GPs. The UK is quite successful in terms of access as it has many after hour services including A&E, NHS Direct and after hour GP services (Boyle, 2011). These services will maximize access to health care, as more people will be able to obtain the care they need in the time that they require it. The structure of the UK’s health system primarily focuses on the primary level, its impact on access just like NZ, enables entry into higher levels of health care through a referral from a GP. Access in the UK is beneficial to all residents due to the free primary health care being provided along with after hour services.
No health system is perfect. Every health system has certain flaws that could be improved. However, all health systems have something common, they all have a goal to provide care for those in need.
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