PERSONAL HEALTH SERVICES

"Personal health services" are the services that an individual receives from others to address health problems or for health promotion and disease prevention. It is helpful to consider the meanings and implications of each of these words. "Personal" is used to connote attention to improving or maintaining an individual's health state, though that state may directly impinge upon others, either in the family or community—there are emotional attachments to sick persons; an individual illness may diminish family resources and capacities; and illnesses have direct implications for communities, such as in the transmission of communicable diseases or in alternative uses for scarce clinical-care resources. Thus, a personal illness can have a profound impact on others, and on the health and well-being of the general public.

"Health" is not an easy term to define (see the discussion elsewhere in this volume), but in the context of health services, there are important conceptual issues. One, as noted above, is the role of health promotion and disease prevention in personal health services. Since many important dimensions of prevention are related to social behaviors or environmental modifications, they are often outside the usual health care system. Another is defining the boundary of health care in terms of appropriate themes. At least in the past, various community health centers and other medical care organizations provided assistance with housing, clothing, and personal legal matters, as well as referral to religious resources. This is not an issue of worthiness, but rather the implication here is that the content of medical services varies and must be explicitly addressed and defined.

The term "services" also requires discussion. While they often connote formal professional services, the patterns and content of care that impinge on a sick individual come from a variety of sources, many of which are neither professional nor part of any organized healing system. The same might be said of the administrative connotation of the term "services," implying not only a single health practitioner, but also care received from a variety of informal sources as well as from well-developed organizations and agencies. In fact, the history and sociology of health services suggest that most sick persons receive health care from diverse sources. Based on anthropological and other studies, there is evidence that all cultures have appointed healers to deal with infirmity. In some societies, these healers may be thought of as using folk, religious, or magical methods; and the sources and content of their lore may not always be clear. In these instances, healing takes place largely in the community, and generally outside of clinics or institutional settings. Interestingly, studying the lore and practices of traditional healing systems, usually in developing countries, has become an important activity in searching for new medicinal or other preventive or therapeutic entities that might have applications in Western societies.

In other societies, healers are much more well organized, and they have generally undergone varying degrees of professionalization and administrative organization. In this case, the healing is often performed in varying types of complex clinics and institutions, usually with a great degree of subspecialization. Nonetheless, no healing system totally dominates a given culture or society, and there are always challenges from alternative healing systems. It has been shown in many countries that many individuals seek and receive health care from highly diverse types of healing systems simultaneously.

LEVELS AND DIMENSIONS OF PERSONAL HEALTH CARE

There is no widely used taxonomy for the elements of personal health services, but there are conventional terms to describe the elements of formal health services hierarchies. One example, referring to the complexity or practitioners' discipline or training, is to consider the level of care as either general, specialty, or subspecialty in nature. Another general approach to care levels is the continuum of primary, secondary, and tertiary care. "Primary care" generally refers to personal care that is broad in scope and does not usually address complex, uncommon illnesses. Primary care is generally intended to be the first contact point when a patient suspects illness, and it provides a comprehensive view of the patient, with full clinical and restorative care for a wide range of common conditions, a full regimen of health promotion and disease prevention activities, and continuity and integration of care when severe or complex illness occurs. Primary care may occur in a variety of locations, but there is a clear community emphasis.

"Secondary care" generally represents the acute general hospital and related institutional and specialty settings in the community where such care is provided; it is intermediate in complexity and intensity. It is more likely to be delivered by specialist practitioners, to be more costly than primary care, and to have few of the attributes of primary care noted above. Primary care practitioners may participate in the delivery of secondary care in certain systems.

"Tertiary care" is the most complex, expensive, and technologically intensive level of care. It is generally available in fewer locations, is extremely resource intensive, and is mostly conducted by subspecialists. Examples include the most sophisticated trauma care, burn treatment units, bone marrow and organ transplant units, and complex types of surgical procedures. Also generally included in tertiary care are rehabilitative and restorative care, which are also a major component of tertiary prevention.

Another axis for understanding personal health care is the notion of "basic health care" versus other "nonbasic" health services. Basic care is not the same as primary care, because almost all definitions of basic care in industrialized nations include access to hospital and rehabilitative care, as well as certain tertiary services. Basic health care is a complex construct that is often the subject of considerable controversy. This controversy stems from diverse moral, social, and economic values about a set of care activities to which all persons in a given society would, or should, have access, if any should be provided at all. The complexity in defining basic health care is illustrative of the nature of personal health care in general.

To begin, a basic set of services might be defined in terms of affordability to individuals and societies. Thus, for fiscal, cultural, and historical reasons, the content of a basic set of services would differ in diverse societies and countries. The content of basic health care would be very different in rural China than in the suburbs of major American cities. Even within a particular country, obtaining political and economic consensus on whether, and how much of, a society's common resources should be provided for a set of basic services is often difficult. Some of this is related to varying views on taxation and the appropriateness of helping programs; other issues relate to moral or value judgments on specific elements of the basic "benefit package." For example, there is great contentiousness about the provision of therapeutic abortion, and about applying stem cells for organogenesis.

Variant views of the content of basic health care and the service package may also occur because of judgmental differences about which services are basic and which are discretionary. Some of this stems from professional and patient competition for a relatively fixed amount of resources, and, within a particular medical system, this is often at the heart of conflicts over basic-care content. For example, cosmetic surgery is often considered to be discretionary, but not all citizens of a given society would agree. Also, there is typically conflict over whether resources should used to provide very expensive services, such as bone marrow transplant, to a few persons, or whether the resources should be used to provide comprehensive primary care to many people. No matter how expensive or rare certain medical procedures may be, it is often politically and morally difficult to explicitly deny a critically ill individual such a service, especially in a more affluent society. Yet the reality is that there are economic and societal limits on the amount of care that can be provided, and a system for rationing and allocating personal health care is always present, even if it is sometimes inconsistent, implicit, and informal.

Sometimes there are diverse opinions concerning the delivery of preventive and health-promotion services as part of a set of basic health services. Prevention is a very important part of clinical care, but preventive services can be expensive, and will thus inevitably compete with illness services for fixed resources.

SOURCES OF PERSONAL HEALTH CARE

There are many sources of personal health care for individuals. These include institutional settings; emergency departments; practitioners' offices; special clinical settings, such as ambulatory surgical centers; and less formal clinical settings in schools, workplaces, and recreational facilities. Formal health services, depending on how they are defined, can be received almost anywhere, including the modest community facilities of some developing countries, sites where nutrition advice or psychological counseling are offered, long-term care facilities, retail pharmacies, and ambulances and other medical transport units. Today, more personal health care encounters occur in the ambulatory setting than in all other settings combined. In fact, the proportion of encounters occurring in institutional settings, such as hospitals, nursing homes, chronic-care facilities, rehabilitation units, and some hospice programs, is generally declining. There are several reasons for this, including their increased geographic distance from most persons, their generally higher costs, the intense amount of requisite labor and technology, and their lesser desirability to patients.

An increasing amount of personal health care is being brought into the home; and sometimes this care can be as complex as that occurring in many ambulatory care or institutional settings. Complex treatments, various kinds of medications, physical or occupational therapy, and chore services have all been brought to the home for reasons of efficiency, quality-of-life, and convenience. Electronic technologies have also brought personal health care into the home in the form of telemedicine. This can represent a great many forms of care, including routine conversations with health professionals, educational activities with health educators or other professionals, automated educational activities or queries about health status, disease management reminders, videoconferencing, and the transmission of physiological and biochemical information relevant to medical practice. Telemedicine has also been used to provide personal health care in special remote settings, such as jobsites or in the military.

The context of care for individual illnesses or for prevention and health promotion also includes less formal health care and healing activities that are not conducted by health professionals. Two of the most important types of informal care are care-giving, which is provided by lay social networks and organizations, and self-care. The most important lay caregivers are families, but such care may also be provided by other relatives, friends, colleagues, the clergy, or representatives of charitable organizations. This source of care cannot be underestimated in terms of amount or importance, and it is an essential complement to formal caregiving within or outside the home, particularly for those with chronic illness and disability. Caregivers assist with major or minor aspects of personal care, including: (a) dispensing of medications and other treatments, (b) providing appropriate nutrition and exercise regimens, (c) assistance with basic personal hygienic activities, (d) general care of children, elders, and those with special needs, (e) transportation to medical facilities or other locations, (f) physiological monitoring, and (g) emotional support through complex illnesses. Caregiving may be extremely burdensome to the caregiver, and it may be detrimental to their emotional and health status.

Self-care is also a necessary and integral part of personal health care. It takes many forms and is often derived from experiences and education within the mainstream care system. Most persons with acute and chronic illnesses must take part in their own care. This might involve physiological and biochemical monitoring, such as blood pressure or blood sugar for diabetes mellitus; communicating a changing health status and symptom manifestations; actively complying with treatment regimens; and even modulation of specific treatments according to signs, symptoms, and other personal data. Self-care also involves health promotion and disease prevention. Much of the burden of maintaining healthful behavior falls to individuals themselves, and while there should be adequate educational and informational resources, including health professional counseling, personal attention to minimizing disease risk and maximizing health status remains critical.

As noted in the introduction, no matter how the mainstream healing system is constituted, there are often alternative healing systems and practices. In most Western societies, a substantial amount of "healing" and perceived prevention comes from alternative or complementary healers and from personal self-care practices. For example, in Western countries, there are many forms of alternative prevention or healing activities that lie outside the orthodox allopathic health care system, and these are often used simultaneously within mainstream care. A substantial proportion of persons take a variety of herbs, nutrition supplements, and other products for health purposes without instructions from mainstream sources. It is likely that all cultures, to a varying extent, indulge in multiple healing systems and practices, and conflicts among them to become dominant are often contentious.

ACCESS TO HEALTH SERVICES

Whatever the content and nature of personal health services within a society, an important dimension is access to that care. "Access" not only implies that individuals and families can easily avail themselves of necessary services for preventive and curative reasons, but also that these services will be used appropriately; and not overused. There can be many barriers to personal health care. The most important are economic barriers, and most countries have made some attempts to minimize these. However, many other actual or potential barriers exist, including poor geographic access, particularly in rural and inner city areas; cultural barriers, in both communication and treatment beliefs, between patients and professionals; inadequate transportation to care sites; and long delays in receiving care once within the care setting.

THE CONTINUING EVOLUTION OF PERSONAL HEALTH SERVICES

The nature and organization of personal health services, as with other social activities, is in constant evolution. While many of the types of services have been mentioned above, it is useful for historical and rhetorical purposes to describe their continuing evolution, beginning with the base period of the mid nineteenth century, and noting trends and forces that have shaped today's health care system. Many forces shape personal health services, and their relative roles are sometimes difficult to discern. In general, nineteenth-century prototypic Western medicine can be thought of as a loosely bound set of individual practitioners dealing with individual patients on a "retail" basis. Medicine in this period has been described as a "cottage industry." Payment for care was almost entirely the patient's and family's burden. Institutional care existed, but mostly for small numbers of patients with mental illness or communicable diseases. Hospitals were often church-operated and were largely dedicated to persons with incurable, progressive, and terminal illnesses. However, nearly all births and deaths took place in the home. Health care then began to evolve due to a variety of important forces.

Incorporation of Science and Technology. The continuing injection of scientific discoveries and technological innovations has changed health care dramatically. It has allowed a much more detailed understanding of the causes and pathogenesis of many diseases and conditions, as well as a substantial increase in illness cure and remediation—a great triumph of the twentieth century. These advances have also fostered tremendous shifts in the nature of personal health services. For example, rapidly advancing medical knowledge has led to the need for professional specialization and an elaboration and extension of professional training programs to achieve more enlightened approaches to treating specific and complex health problems. However, the injection of science and technology has had effects viewed by many as adverse, including the role of specialization in fragmenting health-services delivery, the creation of new and serious adverse effects of some therapies, such as malignancies caused by diagnostic and therapeutic radiation, and the large increase in personal health care costs, sometimes for gains viewed as marginal. There have also been environmental threats, such as those due to inadequate medical-waste disposal. Some new health care technologies, as noted above, have also caused moral and ethical dilemmas that defy easy solutions.

The continued application of science and technology has itself become more formalized. While scientific findings have always been translated into clinical practice, more recently there has been an increasing interest in, and new methods for, summarizing published scientific literature. These techniques include meta-analysis, a formal analytical combination of data from multiple studies of a given topic. Increased attention to published, peer-reviewed, scientific findings has led to evidencebased medicine, a philosophy and method of practice that emphasizes translating summarized scientific findings into clinical decision-making.

Insurance and Other Payment Systems for Clinical Care. Before the late nineteenth century, personal health care was generally paid for by patients and their families, supplemented to some extent by charity care from religious and other philanthropic organizations. Governments provided little health care except for the military and special groups in their charge. As the promise of medical care grew, private organizations, beginning with guilds and labor unions, instituted health insurance to pay for the more complex, expensive care—often related to hospitals. These programs eventually grew into the large health insurance industry that exists today. Simultaneously, governments began to fund more personal health services, often beginning with attention to maternal and child health services and indigent care. Most Western governments also began to provide direct health services, using such mechanisms as community health centers, clinics managed by public health agencies, and the provision of health professionals to communities lacking access to health services. Western governments currently fund a broad range of personal health services, ranging from the provision of nearly all health care, such as in the United Kingdom, to care for only certain segments of the population, such as in the United States, where all levels of government pay over 40 percent of national health care costs. In all cases, these funds come largely from general taxation and employer-employee taxes. Overlying these practices are the professed moral imperatives of providing basic health care to all citizens.

The Increasing Organizational Complexity of Personal Health Care Delivery. Simultaneously with advancing and diverse payment systems for care, there has been a companion growth in larger and more complex organizational forms of personal care delivery. Beginning with small groups of physicians and others joining in common administrative units (group practice), there has been a gradual development of large, complex medical-delivery organizations, ranging from nonprofit cooperatives to for-profit national and multinational corporations. These growing administrative entities may own all the service-delivery components and employ health professionals, or they may work through complex contractual arrangements with physicians, patient groups, insurers, employee/employer organizations, and government agencies. These entities usually have an explicit set of services (the "benefit package"), which are prepaid from various sources; and they may profess to emphasize preventive services (the "health maintenance organization"); but most systems have come under the heading of "health plans" or "managed care." In some situations, managed-care organizations are structured or regulated to compete with each other in an attempt to use market forces to control health care costs. Very few clinical practices are free of some form of managed care or superimposed administrative and regulatory authority.

It is difficult to summarize the effects of corporatization on personal health care, and all health care organizations are constantly reforming themselves. Conceivably, there are several salient strengths for large, tightly administrated care systems. Care costs can be more fully monitored, rationalized, and modulated, and some economies of scale may be present. Quality assurance monitoring—through large information systems, with subsequent interventions—should be facilitated more easily than in multiple, small delivery units. Similarly, the dissemination of evidencebased practice guidelines and continuing professional education programs are likely to be enhanced. Strong liaison with public health programs, such as for surveillance, communicable disease control, and public education, could conceivably enhance these activities when compared to traditional programs working wholly outside of personal care systems. However, there have been criticisms of these systems as well, including inappropriate limitations on the doctor-patient encounter; lack of responsiveness to special community needs; repeated changes in health-system contractors, which promotes discontinuity of care; a lack of competition among plans in many areas; inadequate attention to indigents and others without health insurance; and the avoidance of persons with complex and costly illnesses, such as patients with certain cancers, AIDS (acquired immunodeficiency syndrome), renal failure, or complex rehabilitation needs. Large, consolidated health systems seem to be growing and maturing, however, and a return to small, independent care delivery units is unlikely. Thus, it is necessary for all health-delivery systems to promote continued refinement and efficiency so that societal goals for personal health care can be met.

Consumerism in Personal Health Care. As in other commercial affairs arenas, there has been a substantial impact by health care consumers on the delivery of personal care. This is not new, but the intensity of consumer participation in the care process is increasing. For example, health care organizations have become more responsive to consumer complaints and concerns, and many institutions have ombudsmen to assist patients with perceived service problems. Medical consumers often have places on steering committees or boards of directors, as well as on boards and committees reviewing research proposals for ethical concerns. Patients and others have also had an impact through participation in a variety of community-based organizations and associations, often centering on the concern for a particular illness or type of health service. These organizations work to enhance the amount and quality of patient care, and also participate in the political process to achieve particular goals. Finally, many governmental jurisdictions have laws and regulations that protect elements of consumer rights when participating in health care organizations. The degree to which consumer participation has shaped health care is a matter of dispute, but that some level of enhancement and responsiveness has occurred is clear.

Quality Assurance in the Health Care Setting. While it is likely that most health professionals have always strived for the highest quality of service attainable, modern organizational reforms have added more explicit oversight of the quality of care. These are performed by many different sources, including government-funded organizations and their institutional inspectors, health care insurers, voluntary professional organizations, and health care systems and organizations themselves. Quality assurance takes many forms, including direct monitoring of the care process through record abstraction, assessing health system administrative functions, deriving norms for utilization rates for various elements of care, selecting various index illnesses and procedures for detailed outcome measurement, tracking the health and social problems of health care professionals, monitoring adverse health events due to the care process, and, in some instances, publishing various aspects of hospital and health system performance. Quality assurance programs normally result in both organizational and technical-practice changes, which in general would be the most desired result.

An Emphasis on Prevention. With all the professional, technical, and administrative changes in the delivery of personal health services, there has also been a renewed interest in delivering evidence-based clinical preventive services. In many health care venues, detailed information on patients' prevention histories and needs are collected, and in some places manual or automated reminders assist professionals in the timely delivery of preventive care. Many quality-assurance criteria sets have minimum goals for the proportion of patients who should receive evidence-based preventive interventions. However, preventive and health-promotional services can have substantial attendant costs, and health education and counseling can consume a large amount of professional time. Thus, all health care organizations have had to find efficient and effective ways to deliver preventive care in the context of their professional practices, and this has often been challenging.

SUMMARY

Substantial organizational, technical, scientific, economic, and cultural forces have shaped the nature and content of personal health care, and for sick and disabled individuals, the sources of care have increased in breadth and sophistication. At the heart of clinical care, however, there remains a well-established process that has not materially changed, characterized by communication, education, compassion, empathy, and dignity. Successful health systems must preserve these elements as they evolve and grow.

Robert B. Wallace

(see also: Access to Health Services; Alternative, Complementary, and Integrative Medicine; Economics of Health; Evidence-Based Medicine; Health; Health Care Financing; Inequalities in Health; Managed Care; Medicaid; Medicare; National Health Insurance; National Health Systems; Nurse; Physician; Preventive Medicine; Primary Care; Psychology, Health; Theories of Health and Illness; Uninsurance )

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