Next steps for health-care reform in Nova Scotia

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At last. We have the best plan ever on health care with the recent report by Dr. John Ross. And the government has accepted all his recommendations to stream patients away from overcrowded emergency rooms through ER reforms, collaborative care clinics and in other ways. But what now?

Here's the skeptical argument first, from my Deep Throat in the system, an ER doctor with many scars from the bad old days of politicized health care. Notably, as a consultant, he was involved in the Alberta reforms of a few years ago -- similar to what's being proposed here -- that now seem to be coming apart because of political bungling.

On the Ross plan, he says: "I have been advocating for this approach to rural health for decades. However, I'm at a loss to understand where the human resources are going to come from to make this happen in the next five to 10 years." The Health Department is "flying by the seat of its pants on the costing issue." He expects friction as rural doctors and nurses resist the increased role of paramedics and other health providers. Also, the minister and her staff are into "some very different tobacco if they think this is going to be revenue-neutral."

Health Minister Maureen MacDonald does see it as revenue-neutral -- with savings from shutting down all-night rural ERs going to new collaborative-care clinics that would involve many different health providers. Unlike Alberta, which poured tons of money into new facilities, she expects to use existing infrastructure for rural clinics, pointing out some already exist. She hinges the success of the reforms on the collaboration of the players, notably doctors (in Alberta, a new pay scheme for doctors faced formidable resistance and hindered the reform). And although there's still a ways to go, she points to a "good relationship" with Doctors Nova Scotia, whose president runs a collaborative clinic and was present at her announcement, as was the head of the nurses union who generally applauded the plan.

In the sea-change needed to go from the independent doctor to collaborative care involving other health providers like pharmacists, therapists, dieticians, etc., she says that those who are already in it find it "very satisfying" and are "the best salespeople for the concept."

One notable player in this sense is Dr. Ajantha Jayabarathan, an innovative family practitioner in downtown Halifax who has founded the Healthy Nova Scotians Advocacy Coalition to press the Ross reforms from within, especially in advocating community involvement in reform and in countering our catastrophically bad health habits. She says the government is taking the necessary risks, cost uncertainties or not, since there's no choice. Since only a tiny part of the population -- the elderly, the chronically ill -- account for an overwhelming percentage of health care costs, "even small changes in the system will change our costs."

Even streaming one chronic disease like diabetes -- which is virtually at epidemic proportions and getting worse (costing nearly $400 million a year in Nova Scotia, according to recent figures from the Canadian Diabetes Association) -- away from doctor care and into self-care and wellness clinics would potentially save lots of money, she says, let alone the whole gamut of mostly interrelated conditions like high blood pressure, high cholesterol, arthritis, and so on. In this scenario the doctor remains the ultimate authority, but doesn't do the routine stuff.

Meanwhile, back to the big picture. It's true, as the opposition leaders are pointing out, that not much has happened yet. The few clinics that have sprouted up are encouraging, but in terms of structural changes, as my informant puts it, the one real change over the last couple of decades was the creation of Emergency Health Services, the ambulance system, by Dr. Ron Stewart, health minister in the John Savage government.

Since he's also one of North America's foremost experts in emergency medicine, with a huge reputation in the U.S. where he established the ERs in the biggest hospitals of Los Angeles and Pittsburgh, I checked with him where he teaches at Dal Medical School. He's foursquare behind the Ross reforms -- it's what he envisioned himself way back -- but feels the report "doesn't give paramedics the prominence they deserve." He thinks paramedics, trained to the level of physician's assistants, should be manning the rural overnight emergency centres and doing the "first triage" of what is an emergency and what is not. Given the shortage of nurses, he says, this only makes sense. He may be ahead of his time, again.

Meanwhile, on where we're at: Maureen MacDonald has scored a big political victory with the Ross report, which is raising few objections of principle, if any. She can claim that she has fulfilled the promise to keep emergency care available 24 hours a day, even if the actual old-fashioned ERs are not. Just getting rid of that sterile debate is a big step forward. Now, if -- if -- we can only take the next few steps, including an improvement in public health, we'll be among the leading jurisdictions in this.

Ralph Surette is a veteran freelance journalist living in Yarmouth County. This article was originally published in The Chronicle Herald.

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