6. Healthcare
6.5 Polyclinics
Now let's talk about polyclinics. What exactly do I mean by that? How should they be organized? Who decides where they are located?
In our system, a polyclinic is a building under state administration to which doctors are assigned. The polyclinic provides these doctors with premises, administration, and shared resources such as reception and waiting rooms. Every polyclinic makes sure to house all the specialist fields necessary for the citizens' checkup day. Each is responsible for approximately 4,000 citizens and houses about 20 doctors (meaning 50% of all doctors work in polyclinics).
Each polyclinic hires doctors in pairs for each specialty, for example, two dentists. The polyclinic will ensure that these two doctors understand each other well and can work well together.
Firstly, they share the premises: at any given time, only one of them can work with patients. The other doctor is limited to paperwork at the same time.44
Secondly, the two share a budget for equipment (with the amount depending on the field). This is again something the state doesn't want to micromanage. Doctors should be able to decide how best to use the limited resources. Important: The equipment is tied to the polyclinic, not to the doctor! If a doctor moves to a different practice, the equipment doesn't move with them. This is important, among other reasons, because the two doctors in the same field jointly decide which equipment they purchase. For equipment usable in multiple fields, all those doctors pool their budgets. The order is processed centrally through the polyclinic or the state. But it’s the doctors who determine the choice of equipment.
The decisive advantage for the public treasury is that this organizational method neatly halves the costs for equipment and premises! Apart from that, it needs two doctors per specialty and polyclinic to make always having all kinds of doctors present for checkup days possible. And even then, floaters are still needed for when both doctors in a polyclinic happen to be unavailable at the same time (Which already happens when one doctor is on two weeks of vacation and the other is on their days off during the week).
I also see advantages in having a medical colleague to work closely with. If you have a difficult case, you can discuss it with someone. Even a joint consultation is easily organized. The state doesn't micromanage. There's no rule that says: That kind of thing isn't allowed! Everything the state does is to control how good the outcome is. It does this as objectively as possible and pays the doctors accordingly. Everything else is the responsibility of the doctors.
Of course, the polyclinics could also be made larger: responsible for 8,000 inhabitants, with 40 doctors, 2×2 doctors per specialist field. That would make the concept work just as well and require fewer floaters. It could even be mixed: some large polyclinics and some small ones. In large polyclinics, some pieces of equipment would also only need to exist once, instead of being duplicated across the two smaller ones. On the other hand, I can well imagine that the working atmosphere in a polyclinic with 20 doctors, where everyone knows each other, is more pleasant and less bureaucratic. Also, with more polyclinics, the distance to patients is shorter on average. Twenty doctors is the minimum size that works, which is why I have explained my concept with that size.
What about hospitals?
Compared to polyclinics, where doctors largely organize themselves, there is a much more structured process here. After all, there must always be enough doctors present for the inpatients.
This means that the state cannot simply attribute outcomes to single doctors, because no doctor is solely responsible for any patient, nor does he make decisions independently.
Instead of trying to develop a concept from the satisfaction, competence, and efficiency data of the entire hospital that leads to the right incentives for everyone involved, I propose something simpler.
The state avoids micromanaging doctors by paying them based on their success. This, combined with their professional ethics, gives them the motivation to do the right thing. Motivating a hospital as a whole with money won't work. But we can motivate the county to manage the hospitals in its area well! If a county doesn't do so, then that’s a very good topic for the local election campaign. Local issues should be local. And what problems a particular hospital has, that is definitely local.
Based on the workload of doctors in polyclinics, the state knows the level of need for medical care in each county. After all, that doesn't just depend on the size of the population, but also on its age structure, the major employers, and regional characteristics. So the state determines a portion of the healthcare expenditure to be invested in hospitals and distributes these funds to the countys. They are only allowed to spend this money on hospitals (the state reviews the spending).
Thus, each county can freely decide where it wants to have one or more hospitals. Who manages these, how exactly the allocation of funds is decided, how many doctors of which specialties are employed, and so on. And since the complete decision-making power lies with the county, the politicians can't pass the responsibility on to anyone else if things don't go well. All possibilities, but also full responsibility. Since the money is earmarked, no county can use it to consolidate the general budget. The money for hospitals must be spent on hospitals or it goes to waste.
I think that over time, a healthy competition will develop between counties to provide good healthcare through their hospitals. While I consider “education is a matter for the states” to be problematic (see Chapter 7.1), “hospitals are a matter for the counties” should shake out better. There is much faster feedback whether something works or not, and neither are incompatible curricula or degrees a problem.
The autonomy of the counties has its limits though: every citizen is entitled to good healthcare. And there is a defined list of health services for which the state pays. So counties can't just do whatever they want with their hospitals.
Since the state manages all health data of its citizens', hospitals are also obligated to transmit this data to the state.
Just as with doctors, the state also takes samples here to measure the competence of hospitals. Citizens can also rate hospitals via the health app, so a satisfaction score is available for the hospitals as well.
If a hospital turns away a patient due to overcrowding, it is obligated to refer them to another hospital. These processes are also recorded by the state.
The state makes all of this data public. The first line of defense is therefore, that no county can keep it secret from its citizens that its hospitals are not functioning well.
If the competence and satisfaction ratings of a county's hospitals fall too low, or if they reject too many patients (thereby burdening the hospitals in surrounding counties), the state will intervene. The state has employees acting as a rapid response team for such cases. The money will then no longer be transferred to the county, instead the state now manages the hospitals in that county directly. And the rapid response team has full authority to fix problems (hiring and firing, merging or relocating hospitals, sifting through all documents, and so on). All findings and implemented changes are made public, including who made which bad decisions when, that led to this mess in the first place. That should be pretty embarrassing for the local politicians and thus an extra motivation to never let it get that far. Once the problems have been sustainably resolved, and at the earliest after the next county election, the hospitals will be released back into the administration of the county.