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Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 

 

 

 

 

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Sunday
May072017

Improving Hospital and Emergency Room Capacity

Of all the telltale signs of mismanagement in Ontario’s health sector by the Provincial Governments of Dalton McGuinty and Kathleen Wynne, perhaps the most glaring is the current, sorry state of Ontario’s hospital and emergency rooms. 

“Gridlock” and “Overcapacity” are terms being used on a regular basis to describe the ongoing overcrowding of hospitals and emergency departments in Ontario. Overcrowding no longer occurs just in a flu season. Hospitals in eastern Ontario are over 100% capacity for most of the year. This lack of capacity has resulted in compromised ability to provide access to care for our most vulnerable citizens at their time of need.

The root of the problem is at the top. Instead of improving access to hospital care to serve our growing population and aging seniors, the Ontario Liberal government chooses to push care to the community and mercilessly underfund those very community health services.

Budget restrictions of the last decade, along with the lack of accessible hospital beds and relative shortage of affordable long term care options, have combined to result in gridlocked hospitals and emergency departments. Today, patients are at risk and it is commonplace to have cancellations of needed elective procedures, longer waits for specialist care, and a myriad of strain and negative health effects on patients and their families.

 

Liberals’ Frozen Budgets Create Chaos

The last five years of austerity funding for Ontario hospitals have been particularly harsh. From 2012-2015, funding for hospital operational costs were frozen. In 2016, hospitals received a 1% increase. Hospital budgets have fallen in real dollars when inflation is considered despite a growing and aging population that requires more services not fewer. It is estimated that hospitals require a 2% increase just to meet inflation, another 2% increase to address aging and population growth, and roughly 1% increase to address higher demand. (I will not broach the subject of the rising hydro and energy costs hospitals must budget for over and above other rising costs.)

The recent Ontario budget included $518 million allocated for hospital operating costs (roughly a 3% increase while the Ontario Hospital Association was asking for more than 5%). The Liberals have called this announcement a “booster shot” but it fails to come anywhere close to addressing the effects of the lack of funding over the past decade. The “boost” would be more aptly referenced in terms of the Wynne Liberals’ re-election efforts.

To address hospital and emergency department overcrowding and their negative effects on patient care, the government must budget responsibly rather than using a stranglehold on patient services in attempts to make up for the billions of tax dollars it has misspent on the eHealth spending scandal, the ORNGE fiasco, a bulging health management bureaucracy, and the one billion dollars a month it is spending on debt servicing charges. This money could have gone a long way to solving the overcapacity problems in Ontario hospitals and emergency departments.

 

There is Lack of Hospital Beds

Evidence shows that minor medical issues do not contribute significantly to ER overcrowding—it is the lack of beds that causes delays in the emergency department. The lack of bed capacity both in the hospital and in the long-term care community limits the ability of the hospital to deal with admissions and important treatment of our most ill patients. If incoming patients who need admission cannot access a hospital bed, the wait times build in the emergency department delaying care and causing waits that can extend from many hours into days. On average, one patient “warehoused” in the ER denies access to approximately four patients per hour to the emergency department.

A surprising fact about how low the last decade of mismanagement has taken our health care system is that Ontario has among the fewest number of hospital beds of countries in the developed world with 2.3 beds per 1,000 people--- ranking close to the bottom behind Turkey.

As part of the 2017 budget, Ontario Liberals are proposing to spend an additional $9 Billion to support the construction of new hospital projects across the province. Older hospitals are being replaced but building new hospitals with fewer hospital beds is not a solution to improving access to care especially when care in the community continues to lag.

Ontario’s growing population and increasing numbers of seniors will need more hospital beds despite the push toward care in the community. The ER overcrowding issue is beyond the point of being managed by doing more with less. Governments must restore additional bed capacity.

 

Alternate Level of Care Patients with No Place to Go

Outside of the hospital, community supports and long term care options also have potential to improve capacity issues within hospitals and emergency departments.

Long term care access is critical to restoring acute care bed capacity within hospitals and to improving waits in emergency departments. Roughly 15% of all hospital beds are occupied by patients who would be better served in a setting outside of hospital.

To avoid hospital gridlock, patients who cannot return home because of cognitive or physical limitations, so-called “Alternate Level of Care” patients, must have timely and respectful transition to more appropriate care. Early in 2017 there were over 3,000 ALC patients waiting in acute care hospital beds. It is estimated that about a third of ALC patients are waiting for a long-term care home. Even for home care in Eastern Ontario alone, there are approximately 3,000 people on a waiting list.

Addressing the home care and long term care needs of seniors including ALC patients is critical to improving capacity of Ontario’s hospitals both rural and urban. For more thoughts on this, please read my previous health priorities article A Way Forward with Accessible Long term Care in Ontario.

Here is something more to think about when considering the need to fund community health services versus hospitals. Over these past years, investments in primary care transformation to community managed services have not resulted in reduced numbers of patients visiting the ER. Statistics show that visits to Ontario hospital emergency departments rose more than 5% between 2012 and 2016. Patient visits are up and the patients are sicker. So, I suggest what the Liberals have failed to properly address is that our aging population means not only more chronic disease but also more acute events such as falls and infection.

 

If Ontario’s health care system were a patient, it would be whisked immediately to the ER

After a decade of mismanagement under McGuinty and Wynne, the Liberal legacy is: cuts to nurses and front line care personnel, ERs empty because hospitals cannot afford to run them, elective surgeries cancelled because of lack of ER beds, sick and elderly having to endure warehousing on gurneys in hospital hallways. These commonplace signs in Ontario’s hospitals are unacceptable. Our provincial government and health minister must do better at managing the health sector - starting with Ontario’s hospitals and emergency rooms.

 

 

 

 

Reader Comments (136)

R:

But how do we pay for the care?
Acknowledge that tens of billions of tax payer $ have been wasted by the Ontario Liberals through mismanagement and recklessness. That's a start.
May 8, 2017 | Unregistered CommenterMerrilee Fullerton
Responsible use lies at both ends of the problem.

At the risk of misquoting Tommy Douglas, the government is a gorilla using a sledge hammer to crack peanuts. It has proven itself unable to fund, regulate, monitor and implement a health care system. It will not retreat from this simply bcause it is now too big to fail. It will not relinquish redistributing tax revenues and creating electoral favour under the guise of health care.

Having rode this merry go round for decades the best one can hope for is to make the gorilla responsible for the damage it is causing. I doubt you can take the hammer away. Or is this one and the same problem?

The other nd of the problem of responsible use is tied to utizer responsibility. May I remind us of a CPSO case that demonstrats this? A patient sees the family doctor and insists on a treatment for a benign condition. The doctor fails to convince the patient they are "choosing wisely". The patient threatens to complain and the doctor acquiesces to the demand. The patient complains anyway. Now the doctor is found guilty of failing to act in the patients best interest by acquiescing and is a instructed to undergo remedial education.

True, the doctor would have been subject to a complaint regardless of action taken. The expression, "you can avoid the rap but not the ride", comes to mind.

The point being, the consumer, like the gorilla, is unfettered by ethics or financial consideration.
May 8, 2017 | Unregistered Commentereklimek
R

There is little point in pursuing the past for "blame". That is part of our issues, seeking to blame for past behaviors.

How do we economically deal with the issue of free unfettered access to care?

Centrals current position is, it is the providers problem.
It is certainly a problem for providers. Unfettered demand from consumers. The judge has already ruled that "this case" could not break the bank and financial restraint considerations affecting "this case" is not an adequate defense for an untoward preventable outcome.

Patient advocacy versus organzational duty without immunity
May 8, 2017 | Unregistered Commentereklimek
DrK

As you have voiced many times, until the responsibility for care is transferred to the politicians, the providers will just get squeezed more. One can promise as much as one wants with tax resources, but at the coal face, the providers are beginning to bail. The Premier, at some point, needs to own this.
MFO:
There is little point in pursuing the past for "blame".

Centrals current position is, it is the providers problem...........read; 'the providers are to blame.'
May 8, 2017 | Unregistered Commenterg.fraser
Very disheartening to see this.

"Governments may increasingly need to resort to hard budget caps to control health spending. This need not have a negative impact on patient care if it forces all players to seek out efficiency gains, of which there are many to be had, given the vast duplication and redundancy built into the system. But it will require the co-operation of doctors, who, contrary to their self-image, are not free agents, but providers of a government-funded essential service.

Younger doctors, motivated by more noble goals than money, seem to get this. They favoured the Ontario government's offer, acknowledging that there are bigger health-care priorities than doctor compensation. They put their elders to shame."

https://beta.theglobeandmail.com/opinion/ontarios-doctors-dont-get-it-health-care-is-a-team-game/article31449722/?ref=http://www.theglobeandmail.com&
"
May 8, 2017 | Unregistered Commentereklimek
The new budget is an interesting read. Up to a 20% increase in revenues through taxes and fees, etc., but yet over the same time frame, program spending goes up only about 8%. Big raises obviously are occurring in the civil service by 2019.

It is hard to predict economics, but a lot is based on a 65$ barrel of oil, and an 80 cent CDN dollar. One hopes we aren't trying to catch a knife here?

The middle class isn't seeing any improvement with this budget.
Rather topical.

"A Toronto-area hospital’s efforts to get Ilias Spanidis, 88, discharged included threats to send him to a homeless shelter and charge him $1,100 a day to stay, his son says. Health reporter Kelly Grant looks at his case and Ontario’s wider challenges finding room for patients"

http://www.theglobeandmail.com/news/national/ontario-hospital-overcrowding/article34918036/
Rather topical.

"A Toronto-area hospital’s efforts to get Ilias Spanidis, 88, discharged included threats to send him to a homeless shelter and charge him $1,100 a day to stay, his son says. Health reporter Kelly Grant looks at his case and Ontario’s wider challenges finding room for patients"

http://www.theglobeandmail.com/news/national/ontario-hospital-overcrowding/article34918036/
But the experts advised us, the elderly wouldn't be a drain on the system.

Meanwhile the budgets are fixed for increases below COLA for the next 4 years.

One pities those staffing the EDs.
MfO,

We should remind Dr. Fullerton's faithful readers and lurkers who those "experts" were. If only to make sure that their names are remembered the next time someone at Central goes looking for "experts"!
ELB

The names are scattered all over this blog. I m sure DrF, can drag them up if she wishes.

The issue is we planned this mess, and only more money can get us out of it.
The G&M article is a good one. The ERs are flooded. Hospitals are flooded.
Funding for care in the community has not kept up.
All the talk about care closer to home has really meant more rationing of care.
I find it dishonest.

The public has been led to believe that minor medical issues clog up the ERs...this isn't so. The problem is lack of hospital and long term care capacity.

One LHIN CEO told me we can't build more long term care facilities because people will just fill them......and what would that CEO prefer....?
May 9, 2017 | Unregistered CommenterMerrilee Fullerton
MfO, you are correct in part: more money can get us out of this mess. But it has to be combined with more time and investment in the right places.

That means Central might have to learn to play better in the deep, poopy sandbox that it has created for itself. It can't clean up its mess all by itself...hopefully it is beginning to realize that.

Maybe.

Somehow...and this is hard to believe...Central has not yet hit rock bottom. When it does, it will need to reach out for a hand. Unfortunately, the only hands that would reach down are the ones that would only see personal benefit from being associated with Central.

These are not the helping hands that Central needs right now.

The hands Central needs belong to all the groups that it has slapped away for the past five years.

I wonder when this will dawn on Central.
Autocrats never seek help, as they know what is best.

Central is autocratic.

We all want our free stuff. As we know, health care and longterm care are free.
"I wonder when this will dawn on Central." ELB

When it is too late.

The MD providers are angry and will not assist in anyway with the implementation of the Patient 'First' Price reform.

Hopefully how that we have the OMA leadership willing to stand up to the bully Hoskins it will become very apparent just in time for the election that Emperor Hoskins has no clothes.
ELB:

Central is cutting its backroom deals with the groups it needs. All will be fine.
Meanwhile, at central, the same consultants, the same advice. We just need more control. All MDs on salary,and we tell them where they can practice. We own them as "widgets" in our system.
http://app.toronto.ca/tmmis/viewAgendaItemHistory.do?item=2017.BU32.7

As the pressure builds. A 2% increase in taxes in GTA and GOA for 2018, and freezing of budgets. With rent control, cost of housing is about to soar. Stay away from the margins, and find a doctor buddy to look after you, outside of the hospital sector.
How does he do it?

http://www.stcatharinesstandard.ca/2017/05/09/niagara-hospital-ceo-resigns-as-chair-of-lender-amid-controversy

"Richard Leblanc, a professor of law, governance and ethics at York University, said the average financial institution board chairmanship requires about 500 hours of work a year — and up to 700 hours when the institution is in distress, which is the case with Home Capital."

The Progressive Conservatives have questioned whether Smith is able to do his job of overseeing a major health-care system in Ontario — for which he was compensated more than $720,000 last year — while also being on Home Capital’s board.

Premier Kathleen Wynne said that she can only assume Smith is doing his health-care job. “I do not know the details of how he is fulfilling those responsibilities, but my expectation is absolutely, he would be doing that job,” she said. “He’s being paid very well for the job, but more importantly it’s an extremely important job and it’s an extremely complex one, so it’s my expectation he would be doing that.”
May 9, 2017 | Unregistered Commentereklimek
<<All will be fine.>> - MfO

Appreciate your calming tone, MfO, but we all know that it won't.

Ten years of doing business this way should only signal one thing: time to change the way we do business. As the old Einstein quote goes, the definition of insanity is doing the same thing over and over again and expecting different results.

Time to stop doing what got us to this point and start doing something else. It does not necessarily mean a change in political party - although many here will say that it should. Can't disagree.

But we all know that even the Liberals are capable of changing it up if it means staying in power.

So change it up! Now! Please?
ELB,
The Liberals cannot change. The same bullheaded ways in health care have persisted for over a decade. They are strangling health care.
May 10, 2017 | Unregistered CommenterMerrilee Fullerton
Tax and spend.
May 10, 2017 | Unregistered CommenterMovingforwardOntario
ELB:

But none of centrals staff,under 45,have any idea of alternative ways to run things. The old guard, whom we now find out have multiple conflicts on interest (see Home Capital and HOOPP, etc.), know just tax and spend, while the new troops at central, know only central knows best.
May 10, 2017 | Unregistered CommenterMovingforwardOntario
"Central knows best" vs "Tax and spend"
Both are odious.
May 10, 2017 | Unregistered CommenterMerrilee Fullerton
The merging of personnel within health care administration has cross fertlized staff. This may on one hand be good in that familiarity with the adjacent structures may be insightful. So now that everyone is shuffled around within the same circle, who determines salary scales?
May 10, 2017 | Unregistered Commentereklimek
Those in power, at the political level.
May 10, 2017 | Unregistered CommentermovingForwardOntario
The sub-LHINs are being populated with physicians as we speak. They are being told that physicians will have considerable latitude for directing the Patient First agenda, but time will tell.

At some point the elephant in the room that will have to be dealt with is you can't have half the family docs in the province on FFS earning 30 to 50 percent less than those on capitation but both doing the same job.

In a cost neutral environment it should be very interesting how they square that circle.

I remember asking a auto union board member how it was fair prior to an impending strike vote over a pay dispute where you had the younger hires on the line earning $21/hour and the older hires beside them on the line earning $35/hr but both doing identical jobs. When I asked why the older hires could not meet half way on wages with the younger hires his answer was that, "the older hires had become used to a certain lifestyle and it would be very unfair to have to ask them to give that up."

Are we going to hear similar arguments as to why these large income discrepancies as outlined by the auditor general should continue to exist between the various primary care models?
The number of FFS family doctors continues to grow with the restrictions placed on entering fhos. Going back to your analogy, the FHO family doctors make more but not for doing the same job but for doing less. This situation cannot go on forever.
May 10, 2017 | Unregistered Commenterharper
Interesting I had not considered that the number of FFS docs is increasing due to the restrictions on the capitation models. Yes work volume is also very different between the two groups.

It would seem to me that most of the LHIN physician leads across the province are all from the capitation models earning $35/hour using the automotive analogy.
Is there any physician lead at the LHIN who can afford to be away from a FFS service practice?

The corollary is, if they are away from the practice, who is paying them? Or are they all donating their time?
May 10, 2017 | Unregistered Commentereklimek
The sub-LHIN physician leads are very well paid at rates that approximate the daily rate a FHT doc earns based on the auditor general published numbers.

In other words a FFS doc can drop a couple days a week in the office and not see patients and yet come out ahead both mentally and financially by signing on to lead the sub-LHIN.

The King's coin is very hard to turn down and I suspect there is a direct correlation between the higher the coinage and the better tasting the Price-Baker kool-aid.
And each MD hired by the subLHIN, is another voice praising central. The plan is good.
May 10, 2017 | Unregistered CommenterMovingforwardOntario
We'll see how much of the plan is implemented.
There is not much time before the election and the new OMA leadership is a game changer.

First step is to either partially or fully de-rand the OMA membership.
THe OMA will not be deranded. It requires legislation,that will not be dealt with.
May 10, 2017 | Unregistered CommenterMovingforwardOntario
Why couldn't the OMA just unilaterally reduce the fees charged by 50% and not provide a list to the MOH of who didn't pay their dues?

Effectively the same thing without a legislative change, n'est pas?
Can't violate the legislation.

The OMA will NOT be deranded.
May 10, 2017 | Unregistered CommenterMovingforwardOntario
If the OMA cannot derand itself, then let it become lean and mean and give the membership value for their Randed dues.
May 10, 2017 | Unregistered CommenterAndris
The OMA can not win this. Central needs the widgets to do its bidding.
May 11, 2017 | Unregistered CommenterMovingforwardOntario
OMA doesn't need to de Rand itself. Just do what it did in 1997. Come April don't hand the disc over the OHIP so they can take the dues out of the docs' May and June RAs. Couldn't be easier.
May 11, 2017 | Unregistered CommenterStephen Skyvington
Not only is there a correlation between productivity and morale but there is a high but intangible cost to poor morale.

We are already aware of poor morale within our profession as evidenced by the increasing reports of burnout ( as Canary pointed to in his own community ) a condition that drains the energy and the passion for practicing medicine.

Recognizing burnout and anticipating further government oppressiveness and widgetization , many are looking towards the exits.

What kind of victory will it be for the government to have a resentful sullen unenthusiastic widgetized medical practitioner at the coal face?
May 11, 2017 | Unregistered CommenterAndris
Power makes central do things. It is an autocratic system now feeding itself for power. The need to control.
May 11, 2017 | Unregistered CommenterMovingforwardOntario
I'm not sure how many MDs still submit by discs.
May 11, 2017 | Unregistered CommenterMerrilee Fullerton
I do wonder how long the government can keep stomping down the demand for care and squeezing health care. We've had a decade of it and serious consequences in hospitals and with providers and patients.
The cuts to front line care have been severe. Can't go on like this.

I notice that Doris Grinspun is very upset about RPNs replacing RNs.
May 11, 2017 | Unregistered CommenterMerrilee Fullerton
It can go along for quite awhile.

The public are happy with free health care. The debt is ignorable.

As long as the debt, has no cost, this all can continue.
May 11, 2017 | Unregistered CommenterMovingforwardOntario
mfO,
Yesterday I realized I was asking the wrong question to the younger generations: Are you concerned about the government debt that is being rapidly accumulated that you will be required to carry?

The questions we should be asking instead are:

Would you be concerned if you could not afford to have a family?
Would you be concerned if you could not afford a home?
Would you be concerned if your quality of life is reduced significantly?

Those are the questions we should be asking members of the public.
May 11, 2017 | Unregistered CommenterMerrilee Fullerton
R:

But central will provide an assured basic income, provide housing with fixed rent, and free health and social care. There is nothing to worry about.
May 11, 2017 | Unregistered CommenterMovingforwardOntario

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