Ontario’s healthcare: A two-tiered future?

Hospitals across the country have been under financial constraints as provinces try to cope with cutbacks in federal funding. In Ontario, the government has decreed $1.3 billion will come out of hospital budgets over three years. Can hospitals maintain quality of care while undergoing the changes required by the restructuring process?

Already, some doctors — including Carolyn Bennett, now a member of the recently-elected government in Ottawa — advise families to become prepared to be advocates for hospitalized family members. They fear cuts in nursing staff may leave vulnerable patients without the attention they deserve and need.

As well, cost-cutting measures result in some patients being sent home too soon and before in-home nursing care is in place. The result is a patient who suffers and returns to hospital for a longer stay, adding even more expense to the hospital system. Nurses once had time to give patients a soothing back rub; time to comfort, to listen. Now they’re asked to be accountable for less well-trained workers who have taken over parts of their workload. Burned out and frustrated, they worry about the welfare of their patients. The Ontario Nurses Associion has seen the elimination of 5,000 nursing positions and expects as many as 15,000 more could be cut. Some of those nurses may well find a job in community health delivery — the new initiative for nursing homes, for example. But others will have to look for a job in the U.S. or abroad if they want full-time work.

Canadians worry that a two-tier system could evolve from the cost-cutting and restructuring. David Orchard, Chair of Citizens Concerned About Free Trade, warns the 1989 Canada-U.S. Free Trade Agreement and its 1994 extension, NAFTA, have already given American private health service providers the right to set up in Canada and be treated in the same manner as Canadian health service providers. "If the public healthcare system is working well there’s almost no market for a private system," he says. But if the healthcare system is strained to the point where people can’t get the services they feel they require in a timely manner, the door opens for the private sector to step in.

Waiting lists for surgery and line-ups in emergency rooms will push people to look for services elsewhere, predicts Liberal health critic Gerard Kennedy. "Because we’ve had reasonably good services in the past," he says, "there will be a large number of people disposed not to wait very long. They’ll demand private health insurance and soon after that, private health services. And we will in effect bring in two tier health through the back door — through the simple act of mismanaging our current hospital system."

Michael Decter, former Deputy Minister of Health in Ontario, and author of Healing Medicare (McGilligan Books), points out there’s more of an appetite for private services in Alberta than in the rest of the country. He doesn’t feel there’ll be much de-listing of procedures from OHIP that could lead to those services being sought from private sources. But he is concerned new items may not end up on the OHIP schedule, "so the real risk is you have the public system fund the past, and you leave a vacuum for a private tier to fund the future. Then you really will end up with a two-tier system." The Chair of the Health Services Restructuring Commission makes it clear that discussion of a two-tier system is not within its mandate, but rather a matter between the Ontario Medical Association and the Minister of Health. The Commission, Dr. Duncan Sinclair states, "is firmly of the view that we do not believe the future of Ontario’s citizenry is well served by going private."

Although preoccupied with examining health services in major urban centres, Dr. Sinclair anxiously awaited the announcement of a rural health policy promised by the Ministry of Health. In late June, Minister of Health Jim Wilson announced a policy of delivering healthcare for rural areas and the north as close to a patient’s home as possible. The policy called for the creation of rural and northern networks that link hospitals, ambulance, mental health programs, long-term care and community support services.

Hospitals within the regional networks would be ranked according to the level of service available. In Level A hospitals, a nurse would provide emergency triage — assessing, resuscitating and stabilizing patients who would then be sent on to the appropriate hospital. A doctor would provide similar services in a Level B hospital. Each network would have at least one Level C hospital with a 24-hour emergency department and more specialized care within the hospital itself. Level D hospitals — such as Toronto’s Hospital for Sick Children or other teaching hospitals across the province — would then accept patients from these networks.

This new policy would seem to make hospital closures by the Commission in these areas less likely. Cynics note that many of the hospitals are in ridings held by government members. But will you get the quality of care you expect when you go to any healthcare institution? Will the Minister of Health follow the advice the Restructuring Commission offers?

"Accepting the advice could even mean money in the budget," says Liberal Health Critic Gerard Kennedy, "but it doesn’t necessarily mean spending it in a timely fashion. . . and who will pay the price if they don’t? Who’s going to get stuck in the gap that’s opened up?"