Puzzling over hospital cuts

The Ontario government has picked up the jigsaw puzzle box marked "Healthcare," given it a good shake and dumped it out. Just what picture emerges when the pieces are fitted together is a matter of urgent concern for all Ontarians, especially those 50 years and older who are disproportionately higher users of medicare. The examination of those puzzle pieces — discarding some, re-jigging others and, ultimately, fitting what’s left into an effective whole — has been handed off to the Health Services Restructuring Commission, headed by Dr. Duncan Sinclair, retired Vice Principal Health Sciences and Dean of Medicine at Queen’s University.

The Commission, set up at arms-length from the government, has been given the authority to restructure all hospitals in Ontario. It will offer advice to the Minister of Health on the reinvesting of money cut from the hospital system and make recommendations for reorganizing the delivery of other healthcare services necessary for the good health of the province’s residents — services such as long-term care, home care and respite care.

"We don’t really have a health services system," says Sinclair. "We have a collecti of good — often excellent — institutions, organizations, individuals, all contributing to the so-called `system’ in what’s most charitably described as a semi-coordinated way. Our overall mandate is to catalyze the formation of a genuine system of health services. We’ve begun our work with the restructuring of hospitals.

"The second part of our mandate," Sinclair notes, "which we hope to begin at the end of this calendar year or thereabouts, is to turn our attention increasingly to other elements of the system including home care, long-term care, and in particular, primary care. All of which have to be coordinated with hospitals in order to make a genuine system."

The work of the Commission will be finished by April, 2000, although Dr. Sinclair recognizes that the process will not end then. The aim, he says, is to leave a clearly-defined blueprint in place so that health services reform will continue.

But already the arms-length nature of the arrangement has been criticized as a convenient excuse for the government to duck unpopular decisions as revered local institutions are closed. It also leaves communities feeling that the procedure is arbitrary and imposed, with no avenue of appeal.

"It’s a fictitious set-up," charges Max Goldhar, former Chairman of Northwestern General Hospital in Toronto. Northwestern merged with Humber Memorial in March 1996, adding York-Finch Hospital in July 1996 — only to be ordered closed by the Commission in March 1997. "The government is just hiding behind the Commission," Goldhar maintains. "They’re a creature of the government. They’re responsible to the government."

Hospitals are the setting for profound emotional dramas — as television programmers well know — and the stage is certainly set for plenty of drama on this issue. People are extremely anxious that local hospitals survive. Unfortunately, the restructuring process has not sufficiently involved communities and when facilities are ordered closed, communities become divided and angry.

A case in point: Criticism abounds over the Commission’s decision to close Ottawa’s Montfort Hospital, moving its French-language programs and services to the newly-amalgamated Ottawa General/Civic Hospital. Prime Minister Jean Chretien, Quebec Premier Lucien Bouchard and others have appealed to Premier Mike Harris to review the decision, stressing the negative way the closure will be perceived in Quebec.

The same Ottawa-Carleton report also recommended closing the Brockville Psychiatric Hospital, located in Solicitor-General Bob Runciman’s riding. But in this case, the government wrote to the Commission asking for a reversal of that decision. More complaints arose when it was announced that a Burks Falls hospital closed in 1992 under the NDP government would re-open, in the Parry Sound riding of finance minister Ernie Eves.

The need for healthcare reform seems to be all but universally recognized. Canada spends a higher proportion of its gross national product on healthcare than almost any other country, with the exception of the United States. Our population is aging and the pressure on the healthcare delivery systems will surely increase. In order to maintain the quality of our health services, costs must be controlled in a reasonable manner. But it’s an enormous task — each piece of the puzzle links with another. Each rearrangement changes the picture.

Although a final report for Metropolitan Toronto had not been issued by early July, some hospitals given notice of closure were already being affected. Some doctors, many of them specialists, and other healthcare workers had already been recruited or were actively looking for work elsewhere. At some point, some departments won’t be able to function due to the loss of key personnel — and replacing them under the circumstances is a mission impossible. As happened in Montreal, hospitals may have to close ahead of schedule, triggering a premature influx of patients in a not-yet-upgraded receiving hospital; healthcare workers confronting career termination may face an uncertain financial future.

Doctors now working in the marked-for-closure hospitals also worry they’ll not be accommodated in larger amalgamated hospitals, in spite of the Commission’s directive that they be given access. Is Ontario about to lose valuable skilled healthcare providers when hospitals close? Will the medical "brain-drain" to the U.S. become a veritable flood?

A Statistics Canada study released this spring noted that more than 50,000 hospital beds were closed in Canada between 1986 and 1995. This meant a third of hospital beds available disappeared as the population rose by 12 per cent. Ontario ranked second only to Alberta with the lowest ratio of available beds — 3.4 beds per 1,000 population. On top of this already-shaky foundation, the Health Services Restructuring Commission expects to eliminate another 4,800 beds in Ontario, just as the largest baby boom in the developed world reached the 50 year old milestone.

"We’re terribly concerned that unless we restructure this system to make it affordable," says Dr. Sinclair, "all sorts of people as they age will not have access to the quality or the accessibility of services that we certainly enjoy."

Our use of hospitals continues to evolve. Advances in medical technology and research have greatly influenced the way some services are delivered. Many procedures that once required hospitalization can be safely done by out-patient treatment, in other settings, even in the home. But has funding for these other facilities, services and skilled personnel been found? Since the Commission will not be examining these services until the end of this year, does this leave enough time to put these crucial elements in place before hospitals close?

Ontario’s Ombudsman, Roberta Jamieson, sounded a warning for government ministries that undertake restructuring. In her annual report she described the misery inflicted on families by the disastrous closing of regional offices of the Family Support Plan (FSP) and the radical reduction of staff. Denied access to funds set aside for them, many families were unable to pay for basic food and housing needs. Jamieson noted that "The consequences of poor planning can cut very deeply," and asked that the lessons learned during the FSP restructuring be shared with other agencies or commissions embarking on similar missions.

People living near a hospital that has escaped closure shouldn’t be complacent, warns Liberal health critic Gerard Kennedy. "You’re going to be on the end of a longer line up. You’re going to have your name on a longer waiting list, because (the closed hospital’s) services aren’t going to be replaced. If they close it in a rush, it’s going to be an even longer wait, because the services that are going to be in place haven’t been built yet."

At the end of June, Minister of Health Jim Wilson announced an infusion of $100 million to improve the care provided to seniors living in 495 nursing homes. Good news on the surface, but the money will not provide new beds. Approximately $70 million is earmarked for nursing and personal care; $10 million for enriching social and recreational activities, and the remaining $20 million is allocated for dietary services.

But will there be enough long-term care beds available when the hospitals close in two years? Community and acute-care hospitals currently house many people in chronic care or Alternate Level of Care (ALC) beds who are waiting for a place in an appropriate facility. Will those patients be assured of a placement? Can the newly structured system be flexible enough to provide compassionate and satisfactory care for all, without leaving cracks for people to fall through?

"The whole northwest of Toronto is going to lose 37 per cent of its hospital beds," warns Kennedy, "and that’s a very big cut that the public has yet to come to terms with. We’re also losing 17 per cent of our funds, so this is a very dramatic change for healthcare." The restructuring of the healthcare delivery system is a bit like operating on a wide awake patient. It’s a complex, dynamic procedure, and the consequences of poor planning or errors in judgment can have hurtful and long-lasting consequences. Let’s hope the outcome will be a healthy one — for all of us.