Health Essay

A plan to end the hospital crisis

There are three main causes of the problems: the flu epidemic, a squeeze on the system and the lack of alternatives to emergency rooms

Michael Decter January 17 2000
Health Essay

A plan to end the hospital crisis

There are three main causes of the problems: the flu epidemic, a squeeze on the system and the lack of alternatives to emergency rooms

Michael Decter January 17 2000

A plan to end the hospital crisis

Health Essay

There are three main causes of the problems: the flu epidemic, a squeeze on the system and the lack of alternatives to emergency rooms

Michael Decter

As Canadians entered the new year, a new poll revealed that Pierre Elliott Trudeau was our most popular prime minister. Rather than basking in the glory of his fully regained popularity, the 80-year-old former PM struggled with the flu in a Montreal hospital bed. Millions of other Canadians were also laid low. Too many arrived at overcrowded hospital emergency rooms. Canadas latest health-care crisis landed just in time to fill the news hole created when the Y2K panic evaporated.

£ The overcrowded emergency room rapidly became the lightning rod for all those disgruntled about Canadas healthcare system. In Canada, no health-care story is complete without a round of the blame game. Yet amidst the finger pointing, Canadians, many severely ill, languished in hospital corridors and toured city streets in ambulances as emergency rooms closed to all but life-threatened patients.

Why does this situation exist in Canada in the year 2000?

There are three chief causes of the current problems. The first is the annual flu epidemic, which, this season, created more business for hospitals as Christmas holidays were taken by doctors and nurses. Peak demand met skeleton staffing. The second is the absence of flexibility in a hospital system squeezed for nearly a decade. The third is the lack of alternatives to the emergency room—in reality, the lack of sufficient investment in the Canadian health-care system of the future.

Imagine if our banks had closed thousands of branches and then, several years later, began installing ATMs. The lineups at the remaining branches in the transition years would have been vast and intolerable. Instead, the banks placed thousands of ATMs in neighbourhoods across the country while leaving most branches open. Now, with the Canadian public shifted to ATMs and telephone banking, branch closures are not an issue. The lesson—build the new before downsizing the old—has not been applied in health care. We closed thousands of hospital beds and dozens of hospitals before making needed investments in home care and community care.

We are rapidly moving to the 24-7 society. Many services

Drugs for the flu

*Tamiflu, approved last week, is the second of the new drugs to reach the Canadian market. *An inhaled version, Relenza, has been on sale since November. The new prescription drugs are, says Marie Louie, a respiratory disease specialist at Toronto's Sunnybrook Hospital, “very good news for flu sufferers.”

and stores operate on a 24-hours-per-day, seven-days-perweek basis. This has shaped our expectations as consumers. The pizza comes in 30 minutes. Why not home care? In health care, there is a sharp divide between the 24-7 health system and the rest. The 24-7 world consists of ambulances, hospital emergencies, a few pharmacies and some home care. But the 9-5 world embraces doctors’ offices, clinics, most pharmacies and most home care.

The consequence of this divide is an overuse of the 24-7 services. Many people go to emergency rooms for information, not because they are certain it is the appropriate place to go. After-hours callers to doctors’ offices are often greeted by answering machines directing them to the nearest emergency room. It is the only game in the health-care town.

We built a system in an era when the key concern was acute care. The trauma victim, the heart-attack patient needing emergency care shaped facilities. But our rising health need is in chronic care. We are living longer and for the most part in relatively good health. Millions of Canadians will learn to cope with one or more chronic conditions such as asthma, diabetes or arthritis. Our health system is not yet organized to support people with chronic conditions at the earliest and most effective point of intervention. Treating acute episodes of chronic diseases in an emergency room is a poor response compared with the benefits of earlier diagnosis and careful disease management.

The emergency overcrowding issue is not the same in every part of Canada. In Alberta, most health services are under a single structure. One organization is responsible for hospitals, public health, long-term care. In Edmonton, that organization is the Capital Health Authority. Executive vice-president Dr. Robert Bear explains Edmonton’s success: “It has not been a rose garden, but we had the capacity to problem-solve right across the system.” Another factor of note is the campaign lead by Dr. Gerry Predy, medical officer of health, to get people to take flu shots. In 1999, Edmonton did even better than 1998 when 70 per cent of the population was vaccinated. Health authorities are not the only advocates of the flu vaccine. Canada’s largest nursing-home chain, Extendicare, ordered mandatory vaccinations for its entire workforce. The result—much lower absenteeism and healthier workers.

Eight provinces have followed the lead of Saskatchewan and adopted a regional management model for health services. Properly funded, this model offers better management of health services and a greater emphasis on a healthy population. In Greater Toronto, responsibility rests with 25 separate hospitals, while accountability rests with a beleaguered minister. It is an open invitation to the blame game rather than problem-solving.

Smaller cities such as Kingston, Ont., are coping better than bigger cities. Why? The answer is that in smaller centres it is easier to co-ordinate hospital, home care and other health services. In a smaller centre, accountability and responsibility are more powerfully aligned. Failure to solve problems is transparent to the local newspaper and population. Accountability and responsibility are direct and obvious.

That ability to manage across the health services is missing in Toronto. The Ontario ministry of health struggles to coordinate dozens of independent entities. Duncan Sinclair, chairman of Ontario’s Health Services Restructuring Commission observes: “We have now, in effect, a single, humongous (and distressingly ineffective) ‘integrated’ health system in Ontario. Everyone who carries an Ontario health card is a member. It is too big and poorly organized for its size.”

A single structure for managing health services is not a panacea. Montreal has a regional board but insufficient resources to meet the challenge. Quebec now spends less per capita on health services than Newfoundland. Structures can help direct resources more efficiently, but only if there are resources to direct.

What is to be done? There are a number of practical steps that could reduce future crowding and inappropriate use of emergency rooms:

Strengthen prevention

• Flu shots for the elderly should be a priority. The federal government could contribute by launching a national advertising campaign to support local and provincial efforts. If all health organizations in Canada vaccinated their workers for the flu, a full 750,000 people would be affected.

• Deal with the housing shortage for the poor. Canada’s disgraceful withdrawal from the provision of public housing has made many of Canada’s poor into Canada’s ill. The

emergency room is the wrong place to deal with homelessness and its consequences.

Build a 24-7 health system

• Make nurses available on the telephone to all Canadians to provide health information without a visit to the emergency room or the doctor’s office.

• Provide more and better-funded home care on a 24-7 access basis. Add quick response teams to emergency rooms so that non-critically ill patients can be sent home safely with a home-care nurse as an alternative to a night in the hallway. Victoria has successfully utilized the quick-response-team model for more than a decade.

• Invest in 24-7 primary care. Organize and fund doctors and nurses to be available in urgent-care clinics.

• Designate 24-7 pharmacies, available within a 15-minute drive of city dwellers.

Invest in long-term care

• Increase investment in long-term-care services and beds. In each Canadian hospital, five to 10 per cent of the beds are occupied by patients deemed, by their doctors, ready to move to long-term care.

New year’s night a father brought his ill child to the emergency room of St. Michael’s Hospital in Toronto. He also brought a pellet gun. When he took a doctor hostage, police intervened, shots were fired and the man died. The radio talkshows, fairly or unfairly, wove this tragedy into the larger tapestry of the emergency room story. This image is in conflict with our pride in Canadian health care. It may be an ominous foreshadowing of what awaits us if we are unwilling to move forward. We can do better. We should. Perhaps by next new year’s, overcrowded emergencies will be as distant as Y2K.

Michael Decter is the chairman ofthe Canadian Institute for Health Information. He has served as deputy minister of health for Ontario and is the author of Healing Medicare.