Dr. Merrilee Fullerton on Healthcare

One of our regular contributors had posted an informative post on the previous journal entry regarding accessing beds in Ontario hospitals for emergency cases using Criticall, particularly neurosurgical cases. It  indicates a true lack of access in 2010. This is not something new but it is easy to be hoodwinked by the science of studying wait times and the systems designed to deal with lack of capacity in a system that is likely to get much worse before we come to our collective senses.

Of course, tens of millions were thrown at neurosurgical cases in the past couple years in an effort to create an improvement but in my own estimation, nothing has really changed. I still wait for months...a year in some cases...for a neurosurgical consult in cases with positive MRI findings. I still have referrals rejected because the fax back reads "due to focus on cancer cases, cervical and lumbosacral cases will not be seen".

I do note that what did change after some money flowed was that neurosurgeons were suddenly quiet.

Looking ahead to an aging population and a population with increasing obesity, diabetes and cardiovascular disease, with all the inherent cerebrovascular complications such as stroke and MIs, it doesn't take a rocket scientist, or even a LHIN administrator, to figure out that things are going to get nastier.

I have copied the post almost in its entirety and hope that it provides a deeper understanding of how poorly our system is equipped to meet the needs of the future, not to mention now.

I will also have a look for Mr. Smitherman's comment.

Here is the post from eklimek:

"I am grateful the discussion is in the press about the shortcoming and unsustainability in providing service.

As some of you probably know there is a telephone communication system called Criticall in Ontario. It is used when an emergency requires treatment not locally available.

In years gone by, when there was surge capacity, it was very helpful in connecting the sending and receiving clinicians and assisted in finding emergent care somewhere in the province. Now with no excess capacity pretty well anywhere clinicians begin to view it as becoming just one more hoop.

Here is how it works. Since Criticall does not know the actual provincial bed availability for the needs of the patient (e.g neurosurgery) , it literally telephonically hopscotchs across the province sequentially ringing up on call neurosurgical services.

Reflect for a second on this. Say you are on call as at the potential receiving end. You also know there is no ICU /NICU or surgical capacity on site because you just took the last bed with the last case. Nevertheless you get called. You are obliged to respond, listen to the story, may choose to give telephonic advice for which shared liability is engendered and still must refuse to accept the case because you lack the capacity to treat the problem. All this, let's say, at 3 or 4 in the morninng.

Meanwhile, on the sending end, typically after 3 or 4 refusals for "no beds" over a similar number of hours of repetition and telephone tag with serial oncall services, the conversation turns to out-of-province care. Of course the alternative is to start over from the beginning, just to see if the bed situation has changed in the last 6 hours.

The new wrinkle is interposition of a medical director near the outset of the process if the patient is to leave the home LHIN. Who knew we really needed another noncare provider in this process?"

Thanks for putting it so plainly, eklimek. As health care in Canada sinks, the band leaders play on....except of course when they are trying to enter the life-rafts destined for the US.

I've moved forward to this journal entry only because I did not want to lose the post in the mounds of other information here. This blog has become voluminous much like some of the patient charts I see that need a volume I, II and III.

Please feel free to go back and visit the previous journal entry. I'll be checking for comments over the next few days. I've left some info there on wait times in Alberta and on the new iPad. Interesting developments..

But while I was fishing for information on how Alberta is planning its strategy for health care (and I do like to check in on Alberta because I've found Albertans to be very pragmatic in their approach to many things), I came across this video which I'll link to in the comments section.

It is nice to put some faces to names that we hear so frequently but also to understand that the term efficiency in health care has little or no meaning because it cannot be reliably measured. Accountability is what we really need to be considering to forge new health care options and I'm glad to see some politicians somewhere in Canada have figured this out.

Without going on further, have a look and listen to this video that describes the new Alberta Health Services Quality and Patient Safety Dashboard ...sounds flashy and you may think it is the same old, same old, just repackaged but I get a sense that we are finally moving on from the ill-defined efficiency quest and instead to a more distinct measurement...

And if I hear any more about seemlessly providing the continuum of health care services while working together to achieve a more efficient health care system....well...I'll have to excuse my gag reflex......

I still remember back in 1984 or so when I was a clinical clerk/medical student at one of the country's major hospitals. The staffman was upset because a large number of beds in his alotment were filled with patients waiting for placement. That means they had been treated at the hospital for some reason, their treatment was finished and they needed to be sent home...or sent somewhere....to a relative's home, to a nursing home, to a retirement home or to a chronic care institution, a hospice or somewhere more appropriate than an acute care hospital.

I still remember the calls of an elderly patient with dementia who used to call out to me as I walked past. By virtue of my female gender she would call out "Nurse! Nurse! Nurse!" and although times have changed , in those days most nurses were women. The first few times, I stopped to see what the commotion was all about thinking that there was something wrong and hoping that I could be of assistance. The nurses across at their station later told me that she did that all day long to whomever walked by and despite all of us feeling somewhat guilty about the limited time we had to tend to her, we had come to the realization that she called out as part of her routine and that after assessing there was no immediate need, we would go about our business as necessary.

This may sound cold and uncaring but the reality was that she needed to be somewhere more homelike and have the stability and structure that daily routines could have provided her. Clearly, there were no relatives capable of taking her home or she would have been discharged long ago. But sending a patient with dementia and incontinence home or even to a nursing home is not really in the cards as most social workers will tell you. They need more care than can be delivered at the usual settings.

I still remember her and many like her. In those days, patient were often restrained for their own safety but thankfully progress has been made on that front.

The reality staring us in the face is that this scenario is playing out in hospitals all over the country to an even greater degree than 26 years ago. The issues associated with alternate level care patients are still not adequately addressed. Yes, 26 years have passed and by all accounts the issues are more widespread than ever before despite ongoing efforts to address them.

Now, Aging at Home Strategies are proposed to assist seniors in staying in their homes. There appears to be little understanding of the fact that there is usually an acute event that brings an elderly person to hospital leading to that person languishing in a hospital bed once their acute care is provided.

The acute event occurs whether the patient has assistance in their home or not. Acute events are often a fall or a cardiac event or an infection that comes on quickly or is resistant to treatment  for some reason (often related to diabetes or the fact that the patient has some degree of dementia). Aging at home strategies will not stop these acute events from occuring. They occur because of the frailty of the elderly person and are associated with aging.

More family physicians and more community care will not stop any of this from happening despite what Health Minister Deb Matthews proclaims.

It seems I am not alone in my thinking. Please see the link to a letter to the editor in the Ottawa Citizen this morning. The writer gives a very good overview of the problems we are facing in local long term care. The same problems repeat over and over across the province and the country.

Minister Matthews is practicing wishful thinking....and that doesn't provide health care as far as I know.

Enjoy any sunshine you can get over the next few winter months here in the land of ice and snow and generate some Vitamin D!

Have a Happy Day...

The tragedy in Haiti may bring out the giving side of Canadians and this is a demonstration of "man's humanity to man". However, there is a  stark contrast between a nation of people who had almost nothing to begin with and whose plight has been made much worse by the recent earthquake, and our own North American culture of excess.

How much of anything is too much?

How much of anything is too little?

As developed countries leap into action speeding aid to Haiti, I hope that there is sufficient organization on the ground to get the water and food and supplies to those who need it.

Meanwhile, back in Canada several statistics are worth pointing out:

* 37% of adult Canadians are overweight

*24% of adult Canadians are obese

* the number of Canadian teenagers ages 15-19 with a waist circumference indicative of high risk for health complications has tripled since 1981.

* the number of young adults ages 20-39 (is 39 a young adult I ask! really?) with waistlines putting them at greater risk for health problems has more than quadrupled.

*over the next five years, Canada's labour force is expected to shrink, reducing Canada's economic potential to its lowest level in nearly 40 years

*less revenue for the federal government means a $18.9 billion "structural deficit" by 2013-14 according to a report released by the Parliamentary Budget Officer, Kevin Page.

* "You can't fix the demographics. Even significant changes in immigration policy are not going to change fundamentally those demographics."-Kevin Page

*"Canada's potential growth rate is going to decline, because labour supply is going to decline in the years out, and that's going to have an impact on government revenues, and over time, that is going to have an impact on government expenditures."-Kevin Page.

* Canada's potential growth in GDP is anticipated to slip to 1.7% in 2014 even if productivity returns to historical average.

*in the 1990s and early 2000's potential growth rate was nearly 4%

*Dalton McGuinty's full day kindergarten for 4 and 5 years olds is expected to have an annual cost of operation of about $1.5 billion by 2015.

*"..while national and provincial revenues are crashing down, provincial spending continues to soar"-Terrence Corcoran

* federal transfers will jump from $30-billion in 2002 to a projected $62.3 billion in 2014-15....money the federal government may not even have.

And while we count on government to provide all kinds of health care and social programs and security and counter terrorism,  and while a culture of dependence is not only anticipated but encouraged, the true "givers" amongst us are diminishing in numbers:

*a recent Cardus study, "A Canadian Culture of Generosity", shows that fewer than 30% of us now account for 85% of total hours volunteered, 78% of total dollars donated and 71% of all civic participation.

*the primary civic core of about 6% of the population does about five times its proportionate share

*a secondary group of 23% of the population does about double its share.

*"Unless action is taken by government to support these behaviours and the charitable institutions that underpin them, the work they perform will increasingly fall to governments that deliver them at a much higher cost to taxpayers."- Ray Pennings, senior fellow and director of research for Cardus

Here in Canada, it appears that we eat too much, exercise too little, give too little, take too much...and nobody calls us on it, especially not policy makers because to call it like it is would be too politically risky and well.... unpleasant.... and maybe even unCanadian.

We really do need a Canadian backbone and at somepoint we are going to have to lift the excess weight and find it.

I'll post the links for the stats I've mentioned and please consider making a donation to a relief fund for Haiti.

Appreciate your day!

Since I started writing about medical issues and the health care system over 5 years ago, I've said many times that health care planning must be looking ahead twenty years out.

Short term planning is all very expedient and politically correct and even necessary to some degree but the  trouble is this usually leads to a culture of IBGYBG ("I'll be gone, you'll be gone").  I give full credit to the Economist's Matthew Bishop for this acronym and it is possible he found it somewhere else but for now I'll refer you to his article in The Economist, "The World in 2010- Now for the long term".

What about the here and now? Most assuredly, we must deal with realities at hand and decisions meant to improve current conditions are not only needed but quite noble. But misplaced nobility is not usually a good thing and has all kinds of unintended consequences driven by fully intentional and usually self-serving motives.

Heading into 2010, my hope is that health care leadership will understand the stark realities of a new economic world and the new financial realities facing our country and our Canadian health care system.

We cannot continue to spend the way our politicians have spent in the past several decades. This is not to say that public health care in Canada must be scrapped-definitely not--but we must understand that good citizenship requires more than paying taxes to government to have it spend it for us in a way that it sees fit.  Good citizenship at all levels requires more understanding of how to be a responsible consumer or maybe even a "frugal consumer" of health care.

This "responsible health care consumption" will require education and expectation of the public regarding the new realities.

Let us not avoid uncomfortable short-term decisions but take action knowing that they must be part of the bigger long-term picture.

An article by Paul Vieira in the National Post today, "T is for Taxes", is well worth reading and refers to Generation T, where T stands for tax. The article describes what many Americans may be looking at in the future as value added taxes are looked upon as part of the solution there.

Although Canadians may not see the same sad face staring back at them when it comes to looking at their financial situation squarely in the mirror, we must similarly be aware that our fate is tied directly to the US.

If the past decade was the "Decade from Hell" as Time Magazine has described....pack some ice, the next 10 years are likely to pose some challenges that will require cool heads and long term vision.

Happy reading and try the twitter link!