COVER

Shocks to the system

JOHN DeMONT June 15 1998
COVER

Shocks to the system

JOHN DeMONT June 15 1998

Shocks to the system

JOHN DeMONT

What happened in Brantford, Ont., late last month differs only in detail from the wrenching experiences of communities across Canada. On May 20, Romeo Cercone, CEO of St. Joseph’s Hospital, received the news he was dreading: confirmation that his 101-bed chroniccare rehabilitation facility will close in April, 2000. “I was numb,” says Cercone. Only a fraction of its 400 employees will have work at the one remaining hospital serving an area population of 125,000, the 220-bed Brantford General. The southwestern Ontario community has tried for six months to muster arguments for keeping St.

Joseph’s open, but members of the Ontario Health Services Restructuring Commission were unmoved. ‘They had made up their minds that there was going to be one facility in Brantford,” says Cercone. “It was ideology, plain and simple.”

Unpopular hospital closures. Huge backups in emergency. Patients kept for days on stretchers in corridors. Long waiting lists for surgery. Disgruntled doctors. Angry nurses. Is the

health-care system out of control? For at least a decade, health-care experts have been preaching the need to revamp the system, to get more care and preventive measures out into the community where they are needed. In practice, however, the pace of the wholesale restructuring that has cut through provincial health-care systems like so many scalpels has been driven not by prudent medical planning but by fiscal priorities—the preoccupation with balanced budgets. And somewhere along the line, many of the provinces got things backwards. They pared back acute-care facilities before they had the necessary rehabilitation and home-care programs in place in communities. “It is a little like the banks shutting down their branches before they’ve built enough automated teller machines,” observes Toronto-based health-care consultant Michael Decter, chairman of the Canadian Institute for Health Information.

Money, naturally, is at the root of the problem. As the federal fiscal crisis deepened, Ottawa slowed the flow of health-care funds to the provinces. (The Canada Health and Social Transfer—the main block

The scalpel of health reform has left painful wounds

of federal funding to the provinces—fell to $12.5 billion in 1998-1999, from $19.3 billion in 1994-1995). Coincidentally, the federal cutbacks came at a time when the provinces were already in the midst of the biggest rethinking of health care since the Pearson government introduced medicare in 1966. The solution, on the face of it, seemed obvious: save funds by shutting down acute-care beds, then use the money to reshape the system to meet the needs of the baby boomers who will be hitting old age within 15 years. A mass of heart bypass patients, for instance, will require help at home after being expelled from hospital within a few days of lying on the operating table.

While the strategy seemed to make sense, the problem has been in the execution. Canadians understandably grow uneasy when they hear of patients dying before being seen by medical staff in crammed emergency wards, as may have been the case in two instances, in Quebec and Manitoba, in the past winter; or when their rural hospitals are downgraded to community-care centres or closed altogether. They are concerned by what they hear about burned-out nurses and about overextended working parents struggling to look after their own aged and ailing parents at home because there are no alternatives in the community.

Whether the chaos represents short-term bottlenecks in the system or deep-seated problems that will only worsen with time is unclear. Decter, for one, says that although some critics—primarily physicians’ organizations—have been “crying wolf for years,” it is a relatively manageable situation. “Some problems will take time to solve,” he adds, “but the prognosis is helped by the fact that people are taking better care of themselves.”

However long it lasts, the disruptions are already making it difficult for people to plan for the future, knowing that the health-care system may become largely unrecognizable. In 20 years, when the oldest of Canada’s 9.8 million baby boomers have reached their 70s, many will require extensive health care. As well, improved drugs, new technologies and less invasive surgical techniques are dramatically reducing—in some cases eliminating—hospital stays for procedures that once required long periods in bed, exposed to disease and infection that could be just as troublesome as the original illness.

The day looms when babies are (again) regularly delivered at home and cardiac patients lying in their own beds are monitored

electronically by doctors and nurses miles away. The upshot, almost certainly, will be a new type of health-care system— one in which hospitals mainly dispense services, and most of the post-treatment recovery, the rehabilitation and chronic care takes place in the home or a less-costly rehabilitation institution. “The goal,” says Duncan Sinclair, head of Ontario’s Health Services Restructuring Commission, which is reshaping the province’s health-care delivery, “is to build an integrated health system, a partnership between a whole range of providers offering a whole range of services.”

A tectonic shift of that sort involves a massive reinvestment.

Preparations are now under way for demolition experts to collapse the empty Bow Valley

Centre, a once-proud 400-bed Calgary hospital that shut its doors in April, 1997. As much as anything, that facility’s

demise symbolizes the shift taking place from big institutions to community-level health care. So far, the pain has been least in provinces like Saskatchewan and British Co-

lumbia, which were already far advanced in their reforms when the fiscal crunch hit. Other provinces have found it more difficult to cope with major funding cuts as they struggle to restructure

their own health-care system.

Consider Nova Scotia, which in the early 1990s enjoyed one of the highest hospital-bed-to-population ratios in the land, but had dropped to ninth place by 1995-1996. Since Russell MacLellan became premier last year, the Liberal government has shored up the system with an additional $100 million for doctors’ pay and a system of tele-medicine—using electronics to keep rural patients in touch with urban specialists. But it was clearly not enough to deflect Nova Scotians from other pressing concerns: the decline in hospital beds—about 3,500 today versus 5,947 in 1986-1987—and the downgrading of three rural hospitals to community health centres. Health care was a big issue when the province went to the polls in April, and MacLellan's Liberals barely survived with a vulnerable minority government.

That is not likely to instil confidence in other provincial governments facing elections as they try to reshape health care. In Ontario, for example, where an election is expected next year, the winter flu

outbreak overwhelmed many emergency departments. And that was even before the 40 hospitals that a commission has fingered for closure have shut their doors. Not surprisingly, Premier Mike Harris’s Conservative government, which has been working earnestly to repair its hardhearted image, has pledged to open 20,000 more long-term-care beds and another 100,000 home-care places.

That is certainly a start. For now, Canadian governments spend roughly $2 billion annually on home care—less than three per cent of the country’s $76.6-billion overall health-care spending. Experts generally agree that is far too little to cope with the emerging

needs. The homeand community-care demands seem staggering. They span the simplest questions—who will bring bedridden seniors their meals?—to the most complex, such as the kind of psychological support the person carrying the burden of the patient’s care will need.

And, inevitably, who will pay for it? Provinces have no obligation under medicare’s Canada Health Act to provide home care. But every province has voluntarily established a system in which patients at home are either looked after by government employees or the work is contracted out to nonprofit or commercial home-care agencies. Overall, though, Canada is a home-care crazy quilt with a wide discrepancy between the levels of services available from one province to another.

That is where Ottawa could come in. Experts like Decter say home-care services should be covered under medicare. One complication could be the stiff resistance from the provinces to allowing Ottawa to set standards and principles for home care, then leaving the provinces to pay for the expensive system. And while federal Health Minister Allan Rock says he is determined to put home care at the heart of the Canadian health-care system, his strategy has been sidetracked by the furore over hepatitis C compensation. That may be bad news for the Liberals who want to get public credit for spending money directly on home care. Before Canadians can become confident that the health-care crisis is under control, there will be many more Brantfords to make them wonder. □