How one hospital copes with the money crunch and the morale issue
The health of nations is more important than the wealth of nations.
—Will Durant, What is Civilization?
In the bright midsummer sunshine, Foothills Provincial General Hospital stands on 85 acres of park-like high ground in northwest Calgary, its weighty dominance reminiscent of a castle of old. Across the front of the building, puffing patients and employees, exiled by the no-smoking rule inside, perch on benches, a stone retaining wall and in wheelchairs. Beside the main entrance, a metal plaque dated 1966 reads, in part: “.. . dedicated to a fellowship as old as mankind: the heritage of service to the sick and the teaching of medicine. ” Last week, that 28-year mission took a new twist: the deficit-fighting Alberta government closed two of the city’s six other hospitals and heavily downsized a third, moving some of their services and personnel to Foothills. However, Foothills officials say their ability to discharge their mission may still be in jeopardy. Hundreds of beds, supposedly no longer needed, have been
closed. So have surgical-care units. Some specialized patient services may be next. There has been no money for new equipment for two years. There have been staff layoffs. Those who remain, except the nurses but including the doctors, have accepted a five-per-cent pay cut. There is widespread talk of poor morale. “There’s a terrible depression among people in the health-care industry in this city,”says Foothills president Dr. Larry Bryan.
Foothills hospital, centrepiece of a complex overlooking the Bow River that includes the Tom Baker Cancer Centre and the University of Calgary faculty of medicine, is no star-crossed aberration. To varying degrees, every one of the nation’s 830-odd public general hospitals is either going through the same thing at the hands of a deficit-plagued provincial government, already has, or is about to. There are several reasons for this. First, the Canadian health-care system—still among the world’s best—is an enormous and attractive target for government budget cutters: in 1993, it cost roughly $70 billion, 10 per cent of gross domestic product, somewhere around $2,500 per capita. Aside from world wars, health care may be the most spectacular venture this country has ever undertaken.
And the most inviting target within that system has proved to be the public general hospitals, which last year accounted for something approaching $20 billion of the total health-care cost. Just about everybody agrees—doctors, politicians, even many hospital presidents—that there are too many hospitals, a consequence of profligate spending in the 1960s when prosperous provincial governments seemed bent on giving one to every neighborhood. In some parts of the nation, the budget-slashing has gone beyond trimming fat and has begun to hit patient services, increase waiting lists for some major surgery, diminish opportunities for medical research, persuade scores of doctors and nurses to take higher-paying, less onerous jobs in the United States and demoralize thousands of those left behind. To look closely at the problem, Maclean’s recently spent four days at Foothills hospital, where the administration, staff and doctors agreed to share their opinions and experiences about life under the budgetary knife.
MONDAY, 10 a.m.: The man in charge at Foothills sits with his hands in his lap, fingers laced, slight of build, a quiet man. “This has been the most difficult period in this hospital’s history,” he says, eyes straying to a framed photograph on the wall of his daughter with a horse. Foothills had expected its budget would be cut by about 20 per cent; the cut will be nearly 33 per cent over four years. (Last year’s budget was $230 million.) “I don’t see how we can do that without cutting programs,” says Bryan. By programs he means services to patients. The government has not yet said what this year’s budget will be, but he is operating on the assumption that he will get about nine per cent less—$20.7 million—than last year.
Bryan says some operations, such as gallbladder removal, have been so simplified by technology that they can be done on a short-stay basis, which reduces the need for acute-care beds. (Foothills once had 900 beds; it now has 574—and 1,800 people on its surgical waiting list.) At the same time, he said, community health clinics and small surgical clinics for simple operations would make it possible to concentrate major surgery and serious illness in a single hospital.
The theoretical future has appeal. The present reality has none. “I’m very worried about all this, but I don’t think you just sort of throw yourself out the window.” Bryan looks at the window and half smiles. His office is on the main floor. Could it get so bad that he would quit? “Frankly, if we don’t get some resolution of these issues quite quickly, I couldn’t continue,” he says. “It’s as though you want to drive from Calgary to Edmonton and nobody will tell you the route. ”
To Martin Hollenberg, better patient care depends on medical research, and medical research depends on big-city hospitals. True, says the University of British Columbia dean of medicine, there is a North America-wide shift to smaller hospitals, community care and to more ambulatory and outpatient services, and doctors are being trained to deal with those changes. “But on the research side, you really do rely on the big-city teaching hospitals,” he says. “We need more community care, but you can’t provide it at the cost of tearing down our teaching hospitals.”
Canada must spend less on health care, Hollenberg says, “but we’re not doing it in a very intelligent way by just slapping big cuts on the hospitals,” he says. The system will always respond well to emergency cases, Hollenberg adds. “It’s the ones who don’t need it tomorrow, but would like to have it tomorrow, who are going to have to wait. It’s not a happy situation, and it’s going to get progressively worse. People are going to be sick longer and not getting back to work as quickly.”
MONDAY, 11 a.m.: Jeanette Pick is the bearer of good news: less than one per cent of Foothills’ patients complain about the service, which, for her, is just as well because she is vice-president, patient services.
“When the times were good in Alberta they were building hospitals all over, ” she says. “It was a good way to get votes. ” Now, she says, if the cutbacks continue undiminished “there will be longer waiting lists without any question. We will start to dilute the quality of care, and we will have to cut or eliminate some programs. ” She mentions ophthalmology, audiology and low-priority surgery. One day soon, the patients may not be as happy with the service.
They remember Bob McMurtry at Foothills; until two years ago, he was the outspoken chairman of the department of surgery at the university faculty of medicine. Now he is the outspoken dean of medicine at the University of Western Ontario in London, not given to equivocation or temporizing.
The Canadian health-care system, says McMurtry, is the most competitive and popular of any in the world. “But governments—and I don’t doubt their best intentions—are blowing it. They’re making bad choices based on wrong information.” At the same time, he says, “we do screwball things like importing $2 billion worth of medical devices and equipment each year into Ontario when we ought to be producing it ourselves.”
His overriding concern, he says, is the threat to patient care. “There is tremendous demoralization in the hospitals,” McMurtry says. ‘Why would you think you’d get the care you need if you have a stressed-out staff and fewer of them? There is frustration, despair and a sense of betrayal.”
A hospital, McMurtry says, “is almost like the modern-day church. Life begins there, life ends there, life is transformed within those
walls. It’s very much at the heart and soul and fabric of Canadian culture. People have a very real sense of pride and identity in relation to their hospitals. That’s a reality and shouldn’t be ignored.”
He paused. “By the way,” he asked, “did you know that of the 11 people who qualified as neurosurgeons in Canada two years ago, 10 went to the United States?”
MONDAY, 2 p.m.: He sits down with a sigh, a quiet, rumpled man in a white coat, thick hair, greying. Patient care is not yet impaired, says family-medicine physician Bill Hall, “but we’re getting pretty close to the bone, and people are starting to wear down because there are fewer of them doing the same amount of work. ” Nurses and support staff are beginning to show up among his patients, he says. “There is no question that we’re seeing increased stress. ”
Hall was born in Vancouver and is associate professor of family medicine at the university next door. ‘We’re being lobbied very actively by headhunters south of the border,” he says, “and I get a phone call a week.” He tells a story about a student who has just finished her training in family medicine and wanted a small-town practice. At age 26, she would have had to work 12-hour days and every other night to earn perhaps $150,000 a year in Western Canada. Instead, she is moving to Montana to work in a community that offered her $250,000, will pay
her liability and health insurance and all her student loans and require her to work only one night in four. “Basically,”says Hall, “I don’t understand why we haven’t seen our whole graduating class go south. ”
Between empty beds and surgical waiting lists, there is a seeming paradox. In 1993, Canadian hospitals had closed more than 17,000 beds during the previous 10 years but all of them had waiting lists of one length or another—and still do. For example, the Victoria General in Halifax has reduced its beds to 627 from 809 in less than three years, yet patients wanting elective heart surgery can wait as long as three months. The wait for hip replacement can be a year. The pattem prevails across the country: two months for a hip at Toronto’s Wellesley, three months at the Ottawa General, Foothills and the Vancouver hospital.
Hospital officials offer various explanations: there may be too few operating rooms, the surgeon may be heavily booked, urgent cases always take priority over elective surgery. Another problem is the situation created by the pattem of bed closures. For instance, a hospital may have 35 empty beds but they are of no use to a cancer patient because they are all in a psychiatric ward.
MONDAY, 3 p.m.: Two British medical schools, at Durham University and the University of London, trained Keith Todd to be a pathologist. But he concluded after several years that dealing only with the dead was too depressing, so he switched to the living and came to Canada. Now, he is Foothills’ chief of laboratory medicine. The laboratory undertakes the tests requested by those among the hospital’s 500 doctors who regularly see patients. But tests are expensive, and for a long time, Todd says, there have been far too many of them. At Foothills and numerous other cost-conscious hospitals across the country, doctors are now expected to think twice before ordering tests, to weigh the risk of not doing them, to ask themselves whether the results are likely to influence a choice of treatment or have any bearing on a patient’s recovery. “There was a tendency to substitute testing for diagnosis,” Todd says. “The return from undirected, unsolicited tests is really very low. ” He adds: “If I could save $1 million in lab testing, that would keep a nursing unit open for a year. ”
Gabor Kandel is a 41-year-old gastroenterologist at downtown Toronto’s Wellesley Hospital, which 10 years ago had 550 beds and now has about 350. Kandel and Wellesley president Scott
‘Being sick has become more difficult and more unpleasant’
Rowand, like hands-on physicians and administrators across the country, spend most of their waking hours in the same hospital but live in different worlds. A former Foothills vice-president, Rowand is inclined to define his achievements in numbers: five years ago, the hospital was $12.5 million in the red and is now debt free; more than 70 per cent of all surgery is now done on an outpatient basis (which is high; at Foothills, for example, the figure is 50 per cent); new mothers now go home anywhere from 12 to 48 hours after delivery instead of three to seven days. But he concedes that sending patients home to convalesce transfers health-care costs to family members who have to take time off work to look after loved ones. “There are some serious issues around that,” says Rowand, “but I’m not sure we can afford the health-care system we’ve had.”
Kandel, too, is aware that things have changed. “One of the ways is that doctors are sort of pressured to conserve resources in the hospital; you are swayed to lose your humaneness,” he says. ‘You know, you want to get the patient out that much quicker. Very often, that’s proper from a medical standpoint but maybe not from a humane standje point. The criteria for admitting somebody has I to be that much more rigorous, the criteria for 8 discharging them that much less rigorous.”
TUESDAY, 11 a.m.: The closest most people g ever get to a hospital bed is the emergency deo partment which, because of easy access, has become a kind of surrogate family doctor for hundreds of thousands of Canadians. Bob Johnston has been director of emergency medicine for eight months, long enough to conclude that his staff of doctors and nurses feels trapped between the budget squeeze and the needs of the 55,000 to 65,000 patients who show up every year.
“We’re all more aware of the debate over costs versus care,” he says. “The issue is, can we do without that test, sometimes overnight, sometimes at all. Sometimes patients aren’t very happy with that. ”
Finding out what’s wrong with a patient during the day when all the hospital resources are available is no challenge, Johnston said. Arrive after 4 p.m., “and it’s a fine negotiating stance between the emergency physician and the radiologist who would like to provide an excellent clinical diagnostic service but knows that every time he calls the technologist back, it’s two hours overtime. ”
In the long run, Johnston said, “if the physician truly feels the patient needs test X, Y or Z, they’ll get the test. It may not be this day or this hour, but they’ll get the test. ”
Like Western’s Bob McMurtry, Richard Cruess used to be an orthopedic surgeon. Like McMurtry, he forcefully speaks his mind. Cruess, 64, grew up outside New York City, studied biology at Princeton University in New Jersey, medicine at Columbia University in New York, and did postgraduate work at Montreal’s McGill University where he has been the dean for 14 years.
Cruess says the Quebec government, in search of efficiencies in patient care, has so restricted budgets that hospitals have been compelled to specialize; one, for example, handles urological cancer, a second hospital is responsible for such things as male infertility and paralytic bladder, while a third deals with other urology problems, and a fourth does something else.
“Being sick is never fun, but one of the things that has disturbed me is that being sick in the Canadian system with the budget cuts that have been coming for the past few years has been more difficult and more unpleasant. It is the patient who has suffered with the budget cuts.”
TUESDAY, 3 p.m.: John King, the 38-year-old vice-president of planning and corporate services, is not a doctor but he knows hospitals and is skeptical about some of the changes in the delivery of service.
“It’s a possibility that outpatient and ambulatory services could become as overloaded as acute-care was in days gone by,” says King. “There are even long waits now for some of our outpatient clinics.” Foothills treats about 27,000 inpatients a year, but the number of outpatients has already passed 400,000.
British-born Bernard Badley signed on as a staff physician at Victoria General Hospital in Halifax in 1965 and has wound up running the place. President for the past six years, Badley says he has spent about half that period learning how to do better with less.
“It is increasingly difficult now to maintain services,” Badley says. Last October, he laid off 160 people. Wages were frozen for three years, then cut by three per cent this year. “There is a great deal of unrest in general,” Badley says. “The uncertainty over whether they’re going to remain employed obviously has an effect on morale, has an effect on absenteeism, has an effect on attitude.”
Earlier this year, the Nova Scotia government proposed cutting doctors’ incomes by as much as 30 to 40 per cent. The proposal was hastily withdrawn, but the biggest attraction at the 1994 meeting of the Nova Scotia Medical Society was U.S. recruiters. “That’s ominous,” says Badley.
WEDNESDAY, 8 a.m.: A lot of what doctors do, says René Lafrenière, things like breast examination and childhood checkups, can be done by nurses. That notion made doctors nervous a few years ago, says the Shawinigan, Que.-born, McGill-educated director of surgery, and it is only slowly gaining acceptance.
“Now we have the financial incentive to make that change, which is the wrong way to do it,” he says. ‘You should change because it makes sense to change, not because you’re financially up against it. ”
Echoing the fear of all the people who are trying to make hospitals work better while saving money, Lafrenière muses: “Once you’ve reached the top maximum improvement and you still have to cut down, what do you do?”
Eldon Smith is dean of the University of Calgary faculty of medicine, Foothills’ next-door neighbor. Last year, the Alberta government asked citizens what they wanted from their health-care system. “The answer they got,” said Smith, “was that people wanted a community focus, a focus on wellness—that is, disease prevention—rather than treating diseases once they occurred. But there is no evidence that we can prevent many of the diseases that people think we can—and there is no evidence that prevention is going to be any cheaper than the way we currently do it.”
WEDNESDAY, 7 p.mA frightened elderly woman, tubes in her nose, clutches her husband’s wrinkled hand and endures the chest pain. It should have subsided by now, but it has not. The doctors in the emergency department where she lies wonder why her heart medication is not working. Her husband is worried. He gently disengages her hand, walks aimlessly through the moving jumble of nurses, orderlies and residents, stares at a distant wall. Then he goes back and holds her hand again.
A nurse writes on a wall chart with a felt marker. Patients’ names and apparent ills: “anemia,” “seizures,” “chest pain,” “CVA” (cardiovascular accident), “SOB” (shortness of breath).
Ian Wishart, 31, has finished his residency in emergency medicine and talks about the cutbacks. “The party’s over,” he says. “I’m thinking about taking my American exams to keep my options open. ” Bonnie Sproule, 44, has been a nurse for 24 years. She looks around at some of the 36 beds, all full. “The stress is increasing, the burnout is increasing, sick time is increasing. ” Darlena Kureishi is the physician in charge tonight. “We see the ones who have been here many times, who abuse the system. ”
A man thrashes about on a bed, an apparent drug overdose. It is his second visit in four hours. “I think he OD’d in the parking lot,” says an intern. A nurse yells at the man, trying for a response.
Bob Johnston the director of emergency medicine, has a finger in one ear so he can listen on the phone. He wants to do a CT scan on a young man whose legs went numb while he was driving home. Johnston is trying to convince the radiologist that it is worth spending the money.
ospitals have become a lot more efficient in the past six or eight years, says cardiologist Gary Webb of the Toronto Hospital’s general division, but cost-cutting is creating casualties. For example, he says, the Ontario health ministry has placed quotas on items such as heart pacemakers; if the hospital implants more than its quota, it must pay for the excess out of its operating budget. At the same time, says Webb, the ministry will pay only for standard pacemakers, not the upgrades that some people need.
“The government will do everything in its power to make it seem as though it’s acting in the public interest, but the days of the patient reigning supreme are over,” Webb says. “As a matter of fact, the days of the physician as patient advocate are largely over. We’ve all been co-opted by the hospital budget process.”
Since that process began, had he lost patients who might otherwise have been saved? “Oh, sure,” says Webb. “Whenever you try to cut corners, somebody’s going to be left out of the loop. There are judgments made that this is an acceptable loss rate.”
THURSDAY 10 a.m.: Three angry nurses—Corrine Hingston, Helen Gibson and Judith Ford, office-holders in the Foothills local of the militant United Nurses of Alberta union, meet in the Garden Deli at Foothills. In the unremitting drive by hospitals across the nation to slash health-care costs, the likelihood of being fired or laid off is negligible for doctors, substantial for nurses, lab technologists, orderlies and other support staff. Since January, says Hingston, who wears a T-shirt emblazoned with the UNA logo, 300 of the hospital’s 1,500 fulland part-time nurses have changed jobs. The movement is triggered when a job is eliminated and the incumbent invokes seniority-based bumping rights as does everyone she displaces until someone falls off the end.
“Nurses are running around, working their tails off, trying to fill all the holes in the dike and pretty soon they’re going to crash,” Hingston says. After 30 years in nursing, she earns less than $40,000 a year. When the hospital closed her neurosurgical critical-care unit, Judith Ford, at Foothills since 1981, had to bump someone else. Asked how she felt about displacing someone, she replies: “Well, I had to ask myself whether I wanted to go pump gas or stay in nursing. ” □