THE HIGH COST OF BEING SICK

THE HOSPITALS

Why do they charge so much? Where does the money go and where does it come from? Why can’t a sick person always get into the hospital at once?

June 15 1952
THE HIGH COST OF BEING SICK

THE HOSPITALS

Why do they charge so much? Where does the money go and where does it come from? Why can’t a sick person always get into the hospital at once?

June 15 1952

THE HOSPITALS

THE HIGH COST OF BEING SICK

Why do they charge so much? Where does the money go and where does it come from? Why can’t a sick person always get into the hospital at once?

THEY ALL HELPED TO FIX A LEG

WHEN BILLY fell and broke his leg he was rushed to Toronto’s East General Hospital where he underwent an operation for a compound fracture of tibia and fibula. The three doctors who collaborated at his operation used forty-four surgical instruments, eight different fluids and gases and seven pieces of hospital equipment. The combined salaries of the fifty-two employees who worked on his case amount to $12,530 a month.

Because Billy’s parents were in poor circumstances, but not entirely without resources, he entered the hospital as a public-ward self-pay patient. Being in this category, which all hospitals do not have, meant that Billy’s parents did not receive a bill for the operation itself, which would have cost a semiprivate patient $150.

Billy’s daily rate was six dollars, or three dollars a day less than the cost of providing the hospital’s

many services to each patient. I he operatingroom fee for him was twenty dollars, ten below cost; he paid eighteen dollars, or cost, for X-rays and drugs. The total bill for eleven days presented to his father was $104 — forty-three dollars less than cost. The difference would be made up by the hospital from city and provincial grants.

■ MEDICAL AND NURSING TEAM:

1, anaesthetisf; 2, orthopedic surgeon; 3, operating-room nurse; 4, surgeon; 5, operating-room student nurse; 6, dietitian; 7, orthopedic technician; 8, central supply supervisor; 9, student nurse; 10, general-duty nurse; 11, resident intern; 12, pharmacist; 13, nursing instructor; 14, orthopedic head nurse; 15, blood-bank supervisor; 16, nurse aide; 17, ward aide; 18, physiotherapist; 19, X-ray technician; 20, laboratory technician; 21, operating-

room aide; 22, operating-room orderly; 23, admitting orderly.

ADMINISTRATIVE STAFF:

24, operating-room supervisor; 25, storekeeper; 26, personnel officer; 27, superintendent; 28, pathologist; 29, superintendent of nurses; 30, radiologist; 31, information clerk; 32, switchboard operator; 33, business manager; 34, receptionist; 35, purchasing agent; 36, medical-record librarian; 37, cashier; 38, admitting officer; 39, social worker; 40, plant engineer; 41, secretary.

■ SERVICE STAFF:

42, doorman; 43, maintenance mechanic; 44, electrician; 45, butcher; 46, laundry manager,47, housekeeper; 48, ward maid; 49, elevator operator; 50, pantry maid; 51, laundress; 52, chef.

you to the poorhouse: hospital bills and borrowing from loan sharks. And ninety percent of the borrowing from loan sharks is to pay hospital bills.” This man spoke from bitter personal experience. His wife had been in a private room in a hospital at fifteen dollars a day for thirty days. The charge for the use of the operating room was twenty-five dollars. Because complications followed her operation a hysterectomy—she required blood transfusions ($100), oxygen therapy ($40) and special nurses for seven days ($210). Added to the bill was $88 for drugs, $35 for laboratory tests and $40 for X-rays. The total bill: $988.

In a New Brunswick community I spoke to a woman whose husband had contracted an illness

A MONTREAL businessman, whose wife had just recovered from a severe illness, said to me: “There are two things that can send

of the sensory nerves which left his hands and leet without feeling. Within a few months their medical bills, mostly for hospitalization, had passed the thousand-dollar mark. Formerly managing quite comfortably, they had to lower their standard of living to a subsistence level and the wife had to go to work.

A Toronto man, to pay off a six-hundred-dollar hospital bill incurred when one of his children contracted poliomyelitis, has taken to working five nights a week on top of his regular employment.

All these people have learned at first hand that an ever-increasing slice of the yearly family medical bill is going to pay for hospitalization. A study published in the American Medical Journal—and the same trend is true in Canada showed that the average patient in 1930 spent 13.9 cents of his medical dollar on hospital care; by 1950 this had

risen to 23.1 cents, a jump of sixty-five percent. In 1945 the average Canadian’s hospital bill was sixty-seven dollars; by 1949 it had soared to eighty-five in Ontario and one hundred and twenty in Brit ish Columbia. And it has been going steadily upward ever since.

But there are a few bright spots in the picture. Prepaid hospital-insurance schemes have saved many people from going heavily into debt. However, all too often, these plans limit their benefits. I found that in the course of a year a high proportion of “protected” families had to dig into their purses for amounts ranging from five dollars to seven hundred.

Why have hospital bills assumed such menacing proportions? The fact is that the cost of hospital care has reached the highest point in history. Before World War 1 the average daily cost to t he patient for a public-ward bed was $1.02, for a semiprivate $1.57, and for a private $2.08. Compr Lus with the rate scales 1 found in some of the hospitals today: Halifax, $6-9-11-12; Saint

John, $0-9.50-13.50; Winnipeg, $6.50-7.50-12; Edmonton, $0.80-9-11; Vancouver, $10-17-20. Nor are there any great bargains even in the smaller centres. In Strathroy (pop. 3,700), Arnprior (pop. 4,400) and Cobourg (pop. 7,500), all in Ontario, the rates run as high as $8.50 and $9 a day for a private room. In Brit ish Columbia since 1949 t he rates at the Kelowna and Kamloops hospitals, and at St. Joseph’s Hospital in Victoria, have jumped fifty-two percent, seventy-three percent and one hundred and five percent respectively.

But, as every patient knows, the daily cost of a bed is only a part of the total hospital bill. It’s the extras that add up. A man who recently spent one day in a western hospital, where the per diem rate was eleven dollars, got a bill from the hospital for eighty-three dollars. If you were to have a major operation at the Ottawa Civic Hospital you could pay as much as $32.50 for the use of the operating room, a tank of oxygen would cost eight dollars, while a large plaster cast as much as twenty-five. In any Ontario hospital an RH blood grouping costs five dollars, a blood-volume test ten, a TB culture ten, a quick pathological test of tissue ten. All these are the minimum fees quoted by the Ontario Association of Pathologists.

In Alberta hospitals a gall-bladder X-ray costs twelve dollars, a complete picture of the spine twenty-five. Physiotherapy treatments, which sometimes have to go on for many weeks and even months, are listed at three dollars each. A single electrocardiogram, a chart which electrically records the action of the heart, costs ten dollars. In addition, there are literally hundreds of expensive radiological, pathological and biochemical tests unknown to the layman until he needs them.

Some people suspect that, because of their stiff charges, the hospitals are rolling in wealth. Nothing could be further from the truth. In every province, except where compulsory health-insurance schemes provide an adequate budget, hospitals are in dire financial straits. In Montreal, my interview with one of the administrators of the Royal Victoria Hospital was cut short because he had to attend a special meeting to discuss last year’s deficit of four hundred thousand dollars. All the other Montreal hospitals were roughly in the same boat. I found the same situation in Halifax, Saint John, Ottawa and Edmonton.

Why are hospital statements so drenched in red ink? No one is making money out of hospitals. No cash dividends are paid to shareholders. The boards of directors serve without charge. Physicians and surgeons contribute their services free in hospital wards and clinics to patients who are given free service or charged far below the regular rates. Wages of hospital staffs are not exorbitant. The standard of administration in our Canadian hospitals is reasonably efficient. Why, then, the deficits?

There are at least three answers to this question. The hospital today is offering a much wider variety of services to the patient than it ever did before; the hospital, like any other housekeeper, is the victim of today’s inflated prices; and, last, the hospital is being

Continued on page 55

HERE’S HOW ONE CANADIAN HEALTH PLAN WORKS

THE THOMPSON FAMILY had smooth sailing until last year when Mrs. Thompson had her appendix removed. Baby

Heather, born this year, does not show on account below.

Year____ 1948 They Paid.. $ 20 They Got. $ 15

1949 25 8

1950 44 39

1951 47 200.60

Totals ... $136 $262.60

Extra out-of-pocket bills over the four-year period: Nil.

THE KOSKALUCK FAMILY had their twins in 1949¿ same year father fractured a leg. In 1951 one child suffered meningitis. The plan covered their expenses as follows:

Year .... 1948 They paid .. $ 20 They got ..$ 143.50

1949 44 468.45

1950 65 25

1951 70 92.20

Totals . . . $199 $729.15

Extra out-of-pocket bills over four-year period for items not covered by plan: $349.32.

In Swift Current a unique plan adds compulsory medical care to the Saskatchewan hospitalization scheme

Totals ... $135 $2446.61

Extra out-of-pocket bills include $65 a month for Cortisone. In the six years before they entered the plan the Nixons paid $3,800 in medical bills.

Year .... 1950 They Paid .. $ 65 They Got. $ 763

1951 70 1683.61

THE NIXON FAMILY benefited when they qualified as residents in 1950. Father and son have rheumatoid arthritis; daughter Brenda (above) required extensive dental care.

FRED WOLRICH had a prostate gland operation in 1949 and follow-up treatments in the next two years. When the plan shows a deficit, genera! taxation squares books.

Year---1948 He Paid ... $20 He Got. . .$ 22

1949 25 706.75

1950 25 48

1951 27 29.50

Totals---$97 $806.25

Extra out-of-pocket expenses not covered by plan: $42.

The Hospitals

Continued from page 13

asked to provide services to the community on which it loses money heavily: emeigency service, the treatment, of indigents, out-patients’ clinics, research programs, and the training of nurses and technicians.

Here’s what it adds up to in terms of dollars and cents: In 1900 it cost a group of Ontario hospitals less than one dollar a day to look after a patient; in 1945 it cost $5.82; in 1950 it cost $12.05. Formerly, the hospital’s unprofitable services were largely paid for out of profits made on the semiprivate and private patients. Today, due to inflation, these profits have dwindled almost to the vanishing point and hospital officials are convinced that they can’t hike their rates any higher.

But hospitals aren’t only suffering a shonage of dollars; they’re also faced with a critical shortage of beds and staff and space. With the exception of some hospitals in smaller centres, all the hospitals I visited were despenr.ely short of beds. In a New Brunswick hospital, some of the corridois were jammed. There wasn’t enough room to put up the bed-guards and nurses had difficulty changing the linen, washing patients and giving blood transfusions. At the eighteen-bed hosi pital in Crestón, B.C., emergency patients have to be accommodated on the kitchen floor before a place in the corridors can be found for them.

Hospital authorities are agreed that no more than eighty-five percent of a hospital’s beds should be occupied throughout the year to ensure a high standard of medical care and housekeeping practices. Our larger hospitals

are unable to keep anywhere near that figure. How could they, with so many people clamoring for admission? At the Ottawa Civic the waiting list has gone as high as 1,063. When T visited there a few months ago it stood at 993 of which seventy-one were »regarded as “urgent.” At a hospital in Ottawa for chronic patients a worried white-robed sister told me that their waiting list had passed the four-hundred mark. “Every case is urgent,” she said, “So urgent that some of the people die before we can get them in.”

Recently, eighty-one of the eightytwo nurses of the Calgary General Hospital handed in their resignations. The reasons: underpay, overwork,

overcrowding, and exhaustion and fatigue in carrying out their duties. It was necessary, a spokesman said, to add thirty-one nurses to the staff immediately. The day I visited the Winnipeg General Hospital the nursing staff was twenty percent below minimum requirements. Last September the Vancouver General Hospital was forced to close down two floors, containing seventy-eight beds, because of a shortage of nurses. Indeed, nurses are in such short supply that a number of hospital officials felt bitter about the fact that Trans-Canada Airlines employ two hundred and fifty to three hundred registered nurses as stewardesses.

Why does this shortage of hospital facilities exist? It’s certainly not be-

cause we’ve been sitting on our hands during recent years. In 1947 Canada had about sixty thousand acute, convalescent and chronic hospital beds, federal government hospitals, mental hospitals and TB sanitoria excluded. By the end of 1951 this figure had increased to about 75,500. With funds partially provided by the federal government’s national health program during the past five years the provinces have embarked on an unprecedented expansion program. At tire end of 1948 we had four active treatment beds for every thousand population. By 1950 the ratio rose to five; by the end of 1953 it will have reached 5.57. (The U. S. Public Health standard is 4.5).

But the increase in the number of beds has been more than offset by the increased number of people who want to go to hospital. As an Alberta specialist told me, “Fifty years ago you couldn’t get a patient to enter a hospital; now you can’t get him to leave it.” Take Saskatchewan, which introduced a hospital-insurance scheme in 1947, as an example. In 1925 one person in every ten went to hospital; today the average is closer to one in five—in one community it has actually reached one in two iir the course of a year. In 1925 the hospitals in Nova Scotia were providing an average of a halfday’s care for each citizen per year; by 1948 it had increased to a full day. Dr. N. W. Philpott, of the Royal Victoria Hospital, Montreal, commenting on the modern mother’s insistence on having her baby delivered in a hospital, said: “Whether rich or poor they want the facilities of a modern hospital to ensure a safe delivery.”

The modern hospital’s reputation for safety is well merited. At the Royal Victoria the maternity wards handled 3,527 cases during 1950, including 101 emergencies, without losing a mother. At the University of Alberta Hospital, Edmonton, on a basis of 11,194 patients the death rate was 2.46rj. If you subtract the cancer cases the rate falls to less than eight-tenths of one percent. At another Edmonton hospital, the Royal Alexandra, of 5,801 minor and major surgical operations, there were only sixteen deaths, or about one quarter of one percent. The records of many other Canadian hospitals are equally impressive. That’s why hospitals are so popular.

As we shall see later the tremendous growth of prepaid hospital schemes is another reason for increased hospital usage. For the time being, let’s take another look at your hospital bill and see why it’s so high.

An official of a hospital association made the following comparison: “Suppose you went to a good hotel and got the same service available in the hospital. The hotel room would cost you eight dollars. If you were waited on thirty-seven times a day, not unusual in a hospital, you would pay ten dollars in tips. For three meals a day delivered in your room add another seven dollars. Then, suppose you were bathed in bed, had your linen changed a few times, plus a dozen or so other services that could only be administered by specialists you’d be lucky to get away with one hundred dollars a day. Yet such service is available at a modern Canadian hospital for a fraction of that cost.”

This also points up just how complex an organization the modern hospital has become. It’s futile to compare the cost of hospital care in 1910 or 1920 or even 1930 with the cost of hospital care in 1952. Today the patient gets a much higher standard of service.

Not so long ago all the diagnostic and treatment facilities of the average hospital could be carried in the doctor’s

Continued on page 57

Continued from page 55

little black bag; today they fill dozens of rooms and laboratories and require scores of trained technicians to man them. There are literally hundreds of tests that can be made by the pathologist, radiologist and biochemist which help to pinpoint the patient’s ailment.

Before 1925 the blood transfusion was practically unknown; today it’s common. Montreal’s Royal Victoria in the course of a year gives six thousand transfusions and makes forty-five thousand tests. The use of surgery has been greatly extended.

To provide a wide range of diagnostic and therapeutic services a large hospital requires as many as eighty-seven different kinds of workers. Some of these are seen by the average patient, but most of them work behind the scenes. Who, for example, outside of medical circles, ever heard of a serology technician? Or a scrub nurse? Or a sterilizing technician?

The cost of paying all these skilled people is high. The budget of the Vancouver General, the largest hospital in Canada, now stands at six million dollars, four million of which is for wages. In 1947, only five years ago, the wage bill was $2.1 millions. At the Ottawa Civic Hospital in 1943 there was one staff member for every patient. Then came the eight-hour shift and today there are almost two staff members for every patient. In 1939 a general-duty nurse earned fifty dollars a month; she now gets almost two hundred a month. A maintenance man, who got forty-five dollars a month, now gets one hundred and twenty-five. One official told me, “Even with these increases we haven’t yet caught up to the rates being paid by industry.”

In Toronto a large hotel like the Royal York operates comfortably with one employee per room. Large teaching hospitals like Montreal’s Royal Victoria and Toronto’s General require two employees per patient. In the latter hospital, the rates of pay have doubled since 1941.

Many hospital officials insist that bigger and better hospital staffs and facilities mean that, while you pay more while you’re in hospital, the more effective treatment gets you out faster, hence reduces your total bill. There is a good deal of truth in this claim. Forty years ago, it was not uncommon to remain in hospital a month or more after abdominal surgery. Today you can go home, in some cases, in five days.

The average stay in hospital per patient has been steadily shrinking. At Montreal’s Royal Victoria in 1894 it was 29.3 days; today it is 13.1 At the Winnipeg General the average stay is 11.2 days, while at Edmonton’s Royal Alexandra it’s 9.9 days, excluding chronic cases. The Saskatoon City Hospital discharges the average maternity case in 6.3 days.

Let’s look at some of the other factors that have forced hospital costs up.

As every home-builder knows, construction costs have risen steadily since the end of the war. A hospital consultant, who is planning an eight-hundred-bed hospital for an eastern city at a cost of eighteen million dollars, told me that when the board planned the building six years ago the estimated cost was twelve millions. The new Mount Sinai Hospital in Toronto (351 beds, 86 bassinets) is nearing completion at a cost of $6% millions; in 1949 careful estimates set the price at $5millions. Twenty-five years ago, in most centres, you could build well at the cost of eighteen hundred dollars per bed. Since then construction costs have soared dizzily to eighteen thousand dollars a bed an increase of one thousand percent.

Twelve Precious Minutes

It’s possible to reduce construction costs, but as MacKinnon Phillips. Ontario’s Minister of Health, has pointed out, “You can’t cut corners where human lives and health are concerned.” Features which may be regarded as luxuries in ordinary buildings may not be luxuries in the hospital. The new Sick Children’s, Toronto, like many up-to-date hospitals, has a system of pneumatic tubes by means of which medical records can be immediately dispatched to doctors in any part of the large building. Is this an extravagance? Not if the expense means a saving in messengers’ salaries and the time of busy doctors. Oxygen outlets in every room are expensive, hut they not only provide greater safety for the patient, they also save the staff’s time.

A hospital requires thousands of items of furniture and equipment, which can run into millions of dollars. And this equipment must be constantly modernized.

Consider the matter of sterilization. The old inefficient method was to boil soiled linens and instruments; the new method calls for the use of an autoclave, which kills all bacteria, but also

costs five thousand to eight thousand dollars, and a large hospital needs several of them. By using special high-speed sterilizing equipment in the operating room a doctor can prepare for surgery in three minutes instead of fifteen, a saving of twelve precious mi nites that has saved many lives. Cost of the equipment: eighteen thousand dollars.

The old-fashioned operating table could be purchased for three hundred dollars; the 1952 version, a gleaming device of stainless steel which can turn the patient in any position with a minimum of handling, sells for three thousand dollars. Even the lamp above the operating table, which cuts down heat and shadows, is now priced at eight hundred dollars.

Every housewife knows how little food her dollar will buy today. The i hospitals, some of which prepare three ; quarters of a million meals a year, j have been hard hit, too. Dr. Angus McGugan, superintendent of the University of Alberta Hospital, Edmonton, told me that a meal which cost fifteen cents in 1941 today costs forty-four. “Meals alone cost us $28,740 more a month than ten years ago,” he said. In a group of one hundred and twent yone Ontario hospitals studied, the food bills increased eighty percent during a five-year period, requiring an extra annual expenditure of $7,200,000.

Telephone service costs more, too, so does fuel, electricity, insurance, and kitchen utensils. In 1947 the Univer| I sity of Alberta Hospital paid out I $92,000 for linens, medical and cleaning supplies; in 1951 the bill came to $201,000.

The Case of the Indigent

But the rising cost of building, furnishing and keeping house is only one aspect of the gloomy picture of hospital economics. When I asked a number of hospital administrators why they were going deeper and deeper in the red they replied: “It’s because of

nonpaying patients. We’re expected to take care of them, but no one will give us enough money to do the job.”

In Montreal the Royal Victoria receives from the province and municipality a total of $5.50 per day for taking care of an indigent. But the cost to the hospital to provide a single day’s patient care has been estimated at fifteen dollars. Thus the hospital loses about nine dollars for each day’s care they give a nonpaying patient. This would not he a serious matter if only a few hundred days’ care had to be provided at this bargain rate. Last year the Royal Victoria supplied forty-five thousand days of indigent care. In addition, seventy-five thousand visits were made to the outpatients’ clinics. Each visit cost the hospital $3.25, while they collected only an average of one dollar. Last year’s budget showed a deficit of four hundred thousand dollars or, roughly, the loss suffered by the hospital in providing indigent care.

At the Winnipeg General Hospital 70,806 days’ indigent care were provided. The per diem cost to the hospital for caring for each patient was $9.21 and provincial and municipal grants amounted to $6.50. This meant a loss of $2.71 on each day’s care given. In addition the out-patients’ department was losing money at the rate of one thousand dollars a month. To ensure payment the hospital started a plan requiring all private and semiprivate patients to pay an advance of fifty dollars or a hundred dollars on their bill before admission. As a hospital spokesman explained to me, “We make a slight profit on the paying patient and we need their money to

help carry the less fortunate ones.”

Hospitals in the larger centres often take their worst financial drubbing on care provided for residents from surrounding municipalities. No one in urgent, need of treatment can be turned away by a hospital. If he can’t pay his own way, then it’s up to his municipality to foot the bill. But the onus is usually on the hospital to prove the patient’s inability to pay. This leads to a lot of bickering and, what’s j more important, a waste of the hosj pital staff’s time.

Here’s the sort of thing that happens: A farmer was treated for two months in a New Brunswick city hospital and ran up a bill of $910 which he claimed he was unable to pay. When the hospital presented the bill to the clerk of the municipality where the farmer lived he sent it back. “That man can well afford to take care of his debts,” was the reply. “He’s got money in the bank and, besides, he has land that’s valued at two thousand dollars.” The hospital found the man did have three hundred dollars when he entered the hospital, but most of it had been spent to buy food for his family. As for his land, it was of poor quality and it was doubtful if it would have fetched four hundred dollars at a public auction. How could the hospital suggest that the man give up his land? The hospital has not yet been paid.

Lose Money on Nurses

Hospital boards are giving Increasing attention to the other services they give to the community at a figure below cost price. Take the emergency service of your local hospital. Like the fire department, emergency stands by twentyfour hours a day. Yet such roundthe-clock service is expensive since the people receiving treatment are often not able to pay for it. One accident patient received more than thirty blood transfusions before he was discharged. A twenty-four-year-old girl found on the street in half-paralyzed condition and rushed to emergency by a cab driver required eight hundred dollars’ worth of special drugs, private nursing care and a half dozen operations. The Winnipeg General’s emergency department loses an average of one thousand dollars a month; the Toronto General four thousand. From a purely business point of view these hospitals can’t afford it.

I Hospitals claim they are losing money on their training programs. Ninetyfive percent of all our nurses now receive their schooling in hospitals. This is also true of dietitians, laboratory technicians, occupational and physiotherapists and medical social workers. A student nurse receives twenty-five dollars a month as well as room, board, uniforms. She jives in a residence that costs twelve thousand dollars a bed to build. She needs expensive textbooks, laboratories and skilled instructors. After deducting the value of the services she gives, hospitals estimate that the student nurse costs them anywhere from five hundred to fifteen hundred dollars a year.

Most teaching hospitals carry on an extensive program of medical research. From the point of view of human health and happiness this activity pays handsome dividends, but the dollarsand-cents costs of research have added many a grey hair to the head of the hospital administrator trying to make ! his books balance.

No article about the crisis that faces i Canadian hospitals can avoid a frank discussion of the problem of chronic j or long-term illness. Here’s the situa! tion: there are in Canada, according

j to the most conservative estimates, two hundred and forty-seven thousand

people who are chronically ill. They suffer from such conditions as cancer, heart disease, poliomyelitis, rheumatism and arthritis. Unlike a patient suffering with pneumonia or measles or a broken leg, their affliction will not yield to short-term treatment. And, unfortunately, the problem of chronic illness is going to get worse. We are becoming a nation of old people (in 1900 one out of twenty-five Canadians was sixty-five or more; in 1951 one out of thirteen) and chronic illness is most prevalent among the older age groups.

In all Canada we have five thousand five hundred “chronic” beds; medical authorities estimate that we need a minimum of thirty-six thousand.

Too often we visualize the chronic j as a bedridden patient waiting to die.

Í Hut the truth is that the chronic patient can be rehabilitated. Civen full rehabilitation facilities, medical authorities are confident that ninety percent of all chronics can he restored to partial or total productivity.

What’s all this got to do with hospitals?

In the absence of other facilities many chronic patients end up in general hospitals (or, as they are called, j acute illness hospitals). The hospital ¡ administrator, desperate for bed space, doesn’t want them because a chronic occupying a bed for one year prevents thirty-five patients with acute illness from receiving treatment. Furthermore, the administrator knows that it’s uneconomical to keep a chronic in his institution which has a high-priced staff and expensive equipment, geared to meet the needs of the acutely ill. The ! result is that in practically every Cana! dian community a grim struggle is in I progress. Families unable to care for i chronically ill relatives are trying to ■ place or keep them in a hospital or institution, the hospitals and institu| (ions are trying to keep them out or put them out.

To Stare at the Wall

At a three-hundred-bed hospital I visited in New Brunswick ten percent of the beds were occupied by chronics. One group of twenty patients has been hospitalized for a total of sixty-six years. This bed space could have been used by 2,310 acutely ill patients during that period. Apart from sedatives the chronic patients were receiving little treatment. There was nothing for them to do all day except stare at the wall.

I asked a fifty-five-year-old diabetic, whose wife had been forced to go to work and whose three children were placed in an orphanage, how he passed the time away. He replied, “I worry.”

I found some patients bedridden with the most advanced cases of disease, hut there were just as many who could walk and who could he helped to find their way back to the community. Looking through the ward records I noticed that a staff physician had discharged twenty-one of the twenty-five patients on the ward in Jan. 1951. A year later they were still there. “Most of them have families,” the nurse in charge told me, “but they won’t take them in. Their families rarely come I to visit them for fear they’ll be asked to take them home.”

Because of the lack of chronic hospital beds nursing homes have sprung up all over the country. Some are excellent, hut too frequently shrewd operators regard nursing homes as just another way to make a fast buck. To start with, nursing-home rates are usually far beyond the means of the elderly chronic patient. In Montreal, where the monthly rates range from $130 to $250 a month, proper supervision is lacking. In one home nine

elderly guests steadily lost weight because they were being improperly fed.

Some of the nursing homes across the country are firetraps. Ina Hamilton nursing home, a converted frame dwelling, twelve patients are crammed into the third floor. The only staircase leading to it is twenty inches wide. In one Toronto nursing home, a sixroom bungalow, sixteen patients are crammed together, their beds less ( han six inches apart. Many of them are invalids, partially paralyzed.

Why are such conditions permitted to exist? Why aren’t these nursing homes supervised? In some provinces inspections are required. But inspections are not always made regularly. Indeed, in one of our largest cities, the local authorities are unaware of the location of many of the homes. When the province recently ordered the health officials in one municipality to close down certain substandard homes the request was refused. “What do you want us to do?” they asked, “Throw the old people out on the street?”

Should the State Step In?

Sometimes bewildered elderly chronics find themselves in mental institutions, simply because there’s no place else to put them. A mental health authority estimated that if the Ontario mental hospitals were able to discharge all the elderly patients who shouldn’t be in there the free bed space would he equivalent to one entire hospital.

Often the chronically ill patient winds up in a county or municipal home for indigents. In Halifax I visited the four-hundred-bed Municipal Home, where hard-working staff keep an antiquated building scrupulously clean. “We were never intended to he a hospital,” an official told me, “but we’re slowly turning into one.” Eighty

bedridden patients now fill the infirmary, while the less seriously ill are placed in the “overflow ward” which adjoins it. Only the most rudimentary medical care is available. I was told that with improved treatment facilities many of the guests could be returned to the community, at least temporarily. But the skills and equipment necessary lor rehabilitation were lacking.

Here are some of the suggestions being made by hospital, medical and welfare authorities to improve the present situation.

1. Keep more people out of hospitals. This can he achieved by an improved over-al! public health and medical care program aimed at preventing disease and detecting disease in its earliest stages. Experience with arthritis and rheumatism dramatically points this up. Research has shown that ninety percent of arthritics need not suffer any disablement if they receive treatment early.

2. Let’s face up to the problem of adequately financing ow hospitals. Where’s the extra money to come from? There are only three possible sources of revenue: the paying patient, private philanthropy and government. As for the private and semiprivate patient, hospital officials feel they’re charging all that the traffic will bear. While private philanthropies can raise funds for some capital expenditures like the erection of a new building they can’t be expected to meet annual operating deficits. That leaves the governments, who have already contributed heavily for the care of the indigent sick on the assumption that they are the responsibility of the state. But there is the feeling that governments haven’t gone far enough. Dr. Owen C. Trainor, of the Misericordia Hospital, Winnipeg,

says, “The state (should) assume full responsibility for the hospital care of those of its citizens unable to provide for such care out of their own resources.”

3. We need to build more hospitals, train more staff. Our hospital-building activity of the past five years should he continued. But care should be exercised to distribute the additional beds intelligently. An urban centre providing highly specialized care for the area which surrounds it might need as many as eight beds per thousand population; for the small community four beds per thousand might be ample. In spite of the shortage of beds in city hospitals there are empty beds in the smaller Quebec communities like Sorel and St. Hyacinthe. The same is true of Peterborough, Leamington and Dunnville in Ontario. We should also increase our output of doctors. Special attention should be paid to the expansion of training facilities of nurses and laboratory and radiological tecli-

nicians, physiotherapists and medical social workers.

4. Build hospitals that are. easy to maintain and functional. Some of the new buildings going up are twenty years old the day they open their doors.

5. Better administration and housekeeping practices can reduce operating expenses. A step has already been taken in this direction with the establishment of a graduate course in hospital administration at the University of Toronto.

Enterprise in management has been demonstrated by the new KitchenerWaterloo municipal hospital. Large savings are made annually by making about five hundred items on their own premises. These include soap (from kitchen fat), aspirin and phénobarbital pills, vitamin tablets, ink and furniture polish. A dollar’s worth of germicidal solution is homemade for ten cents; intravenous saline solution, which sells for $1.25 per thousand ccs. is prepared for about eleven cents. Laundry costs have been cut by taking in washing from neighboring hospitals at Galt and Guelph.

6’. Get the long-term chronic patient out of the acute illness hospital. It’s an extravagant practice to keep them in a fifteen-thousand-dollar bed when they can be getting better service in a hospital where the beds cost five thousand dollars and where the facilities are more suitable for their treatment. If possible, the chronic hospital should be near the general hospitals to make use of the facilities when needed.

But the chronic hospital shouldn’t be a place for patients to await death. Every facility to rehabilitate the patient should be made available. At the rehabilitation centre operated by

the Western Society for Physical Rehabilitation, in Vancouver, a fortyyear-old laborer, formerly confined to a wheelchair because of an earlier attack of poliomyelitis, was taught a craft and now operates a thriving shoe repair business.

The U. S. Office of Vocational Rehabilitation drew up a balance sheet on the sixty thousand people they helped during a recent year. Before rehabilitation this group had earned seventeen million dollars; after rehabilitation ninety-five millions. It was estimated that in ten years the federal income tax paid by this group will have amounted to ten times the amount of money expended to help them.

7. Get the convalescent patient out of the acute general hospital. Patients recovering from certain types of illnesses shouldn’t continue to occupy acute illness beds. It’s cheaper for the hospital, and better for the patient, to transfer them to a bed in a convalescent wing or hospital. By the end of 1953 we’ll have .75 convalescent beds per thousand population; medical authorities estimate that we need two beds per thousand.

8. Every hospital should institute a “home-care” program. In simplest terms this program means discharging the patient at the earliest possible moment and continuing treatment in the patient’s own home. Most of the hospital’s services which he needs can he brought to his own bedroom by visiting interns, nurses and so on.

The savings which result from home care, for both the patient and the hospital, are amazing. For example, at the Reddy Memorial Hospital, Montreal, the only hospital in Canada which operates a home-care program, a diabetic who required amputation of a gangrenous toe, was discharged after only five days. Normally she would have had to remain in hospital for about a month under constant supervision. Since the home-care daily rate is three and a half dollars as compared to nine dollars for a semiprivate room, the patient’s hospital room bill was $136 instead of $279, a saving of $143. And home care saved the hospital money as well.

9. We need enough suitable institutions and welfare services for the incurable, the aged and others who require such care. Without such facilities the pressure on our acute illness hospitals to admit people who shouldn’t properly be admitted will continue unabated.

10. The community and medical profession alike should be educated to use hospital facilities economically and intelligently. In the words of Dr. L. O. Bradley, executive secretary of the Canadian Hospital Council, “Everyone in the community must be aware that unnecessary admissions and prolonged hospital stays for reasons of convenience only are piling up our hospital bill and aggravating the present crisis.” In this matter the medical profession, individually and collectively, must bear by far the greatest responsibility since the decision to admit or not admit, discharge or not discharge, generally rests with the physician.

The word “hospital” is derived from the Latin term hospitalis. Its early, historical meaning was “a place of refuge.” Its traditional function has been to relieve suffering by receiving the sick, the aged and the infirm. It is a house of mercy. Regardless of how high the deficits soar its doors must he kept open.

The basic problem that faces us is this: what is the best method of

maintaining our hospitals so that they can render the best possible service, at the lowest possible cost, to the largest number of people? ★