What is a hospital? Seemingly a simple question, but scratch the surface and things get complex very quickly. On the face of it, a hospital is a large, expensive building where doctors and nurses help the sickest people in society get better. Here in Christchurch, the yearly budget for the hospital is a staggering 1.5 billion dollars; but then it does employ about 3000 staff- a veritable army of doctors, surgeons, nurses, clerks, cleaners, cooks, radiologists, orderlies, therapists, dieticians, social workers, pathologists, technicians, engineers, educationalists, students, executives, and managers.
Yet despite Christchurch hospital being around since 1861, and hospitals existing since Antiquity, no-one really knows the answer to questions any designer and manager of a hospital would love to know, like how many beds should a hospital have, how many doctors and nurses are needed, what illnesses should a hospital manage (and importantly, not manage) and how much will it all cost?
Instead hospitals are organised in ad hoc fashion, forever reorganising according to the latest cause of morbidity and mortality, whether that be a viral pandemic, a spike in mental ill-health, or more often than not, a government whim. Funding seems to cycle though periods of boom and bust, money arriving only after a prolonged hospital crisis and multiple avoidable patient deaths.
So, if we are to solve the problem of managing hospitals effectively where do we begin?Accurately defining the problem is usually a good start, yet we can’t go there until we can achieve an agreed upon definition of what a hospital is and does, and this, as far as I can tell, doesn’t exist. If it did hospitals would be standardised by now, built to a blue print that was proven and reliably successful. Perhaps all we can do is look to analogous systems out there that can give us insight into our dilemma.
The car factory model was fashionable for a while. Unfortunately it turns out that supply and demand for cars is a bit simplistic compared to running a hospital. The supply of healthcare here in New Zealand amounts to around 9% of gross domestic product. As for demand, its hard to quantify, but the desire for health care could well be insatiable, perhaps infinite. And, as it turns out, fixing cars is a lot simpler (and cheaper) than fixing people.
I once had a friend who was convinced that being a doctor was like being a soldier, and we, as first year house officers, were the infantry, ordered out of the trenches by our Senior House Officer, to battle opposing specialities in an attempt to gain the upper hand for our patients. As an analogy I reckon he was onto something. Like the armed forces, we are led by a Minister of Health who sits atop health boards, CEOs, Chief Medical Officers, Clinical Directors, Consultants, Fellows, Registrars and House Officers. Health systems are certainly more anarchic that the rigid hierarchy of the Minister of Defence, his Generals, Majors, Sergeants and Privates but like the army we have to respond as best we can to unpredicted demands, to battle on even when our resources are overwhelmed. And like an army we deal in cycles of funding, having to absorb the cost of expensive new technology and treatment, then watching the cash roll in when war is on the horizon. The big question in this analogy though is ‘who is the enemy’? Is it our patients? Probably best not to go there. Perhaps every hospital department is at war, fighting each other over prestige and resource. And who hasn’t, as a junior doctor, been sent nervously into no-mans land with a soft referral, armed with a feeble case of acopia or a chronic pain exacerbation, only to return defeated by the medical registrar, and then listened in as the big guns are wheeled out in a consultant to consultant disposition telephone battle .
My favourite analogy is the health system as a religion. The Hippocratic Oath, as a solemn promise, doesn’t necessarily invoke a divine witness but certainly demands a special obligation to one’s fellow man. The undertones of devotion or of a ‘calling’ are evident. Then there’s the business of becoming a Fellow. Essentially one is admitted or ‘ordained’ into a College that confers special authority, and the right to perform various procedures on the public (can intubation be described as a ritual?). And how much of what we do is based on good quality scientific evidence as opposed to tradition, even myth? Of course I’m doing a disservice to Medicine, we may cause harm but we certainly aren’t on the level of some of the better known organised religions.
Current thinking suggests we are actually employed not in a Hospital, but in a Complex Adaptive System. The study of which is a subset of nonlinear dynamical systems (whatever that means). It’s a weird blend of sociology and mathematics defined as network of interactions which are non - linear (small inputs can lead large effects), that can self-organise, where emergence can occur, that can learn and at the same time be influenced by unpredicted feedback loops and local history. As a system it is open, thus defies boundaries, one part of the system can be entirely ignorant of what other parts are doing, and while it never attains equilibrium it requires a constant flow of energy to maintain organisation. Sound familiar? Currently a Complex Adaptive System is thought to be inherently unpredictable. Yet there is hope. Apparently, with the advance of mathematics, these types of systems will become predictable. And if that were the case perhaps we could finally understand what a hospital is, and so we could organise our health systems effectively, and ultimately, end the ubiquitous boom bust cycles that plague our hospitals.