Equal access to whom?

EDITORIAL

EqualAccessto Whom? I recently attended a forum to discuss quality ofhealth care. The issues centered primarily on access and affordability. Piercing questions arose . Can we afford to offer all the latest technological innovations to all persons regardless of age? Are two levels of health care permissible provided the first level is compassionate and adequate to need? Ought " there be a point at which we cut offexpending public or welfare monies on behalf of people who do nothing or not enough to maintain their own health and well-being? If obesity contributes to heart disease should we refuse to reimburse for treatment ofobese people who refuse or fail to follow diet and exercise regimens? Is there an age beyond which we will not consider use of new treatments even if they add to the quality of life or even if they are life sustaining? The moral and ethical implications ofany or all ofthe answers we might give are complex and sufficiently crucial to change the fabric of our society. But the issue ofwho has access to quality care must await the answers to a more basic question: Who is out there to access? It is useless to legislate equal access to health care services for all when there are insufficient resources to provide those services. I speak not only of money but of human resources . We are repeatedly told there are not enough people to do the job. Not just not enough people to do the job well, not enough people! In the face 6rthis dwindling supply ofwarm bodies, why are we insisting on programs that focus on narrow specialty areas? The more we fractionalize the services to be performed, the greater number ofbodies we need to do the "whole thing." Unlike diversification ofproducts to increase sources ofrevenue, division and dispersion oftasks only means it will take longer to put everything together. There will undoubtedly be duplication, and it will ultimately cost more money. We need good generalists. Whatever you wish to call those who are the frontline carers, they must be prepared to assist those in their charge to recover from illness, regain and maintain health, develop a level offunctional adequacy to meet their daily needs for a life-style of their choice, and protect the vulnerable from further harm or illness. Yes, there is a shortage ofnursing, and no, it will not be solved by telling everyone that you don't need prepared people to take care ofpatients. In the long run it may be better to do nothing than to carry out a procedure incorrectly. The result of an incorrect action may create a problem more dangerous or debilitating than the one it was intended to solve. Incorrectly assisting a patient with severe osteoporosis to turn in bed may result in rib and shoulder fractures. Failure to adequatc1y monitor infusion rate could result in pulmonary edema. The wrong medication, or the wrong dose, or the wrong time could do more harm than failure to give the right medication at the right time. We pay dearly for incompetence-in time, money, and, most wasteful of all, in human resources .