In last month’s column, the question of the appropriate number of hospital beds was raised. A better question might be: why do we need hospital beds in the first place?
Hospitals began as eleemosynary or charitable institutions for the care of the poor. Now, we expect them to provide all levels of care to anyone at any time. Is this even realistic?
Think about the last time you or someone you know was hospitalized. Imagine filling out a survey of that experience that discusses why the hospital stay was required, how the patient and family were treated before, during and after the hospitalization, the timing of each step of the process and the degree of satisfaction with the hospitalization from start to finish.
Patients and family or other support networks can experience stress, frustration and confusion throughout the process. Yet few consider that they have the right to be treated with efficiency and compassion; the two are not mutually exclusive.
How can things change?
Canada has a sickness system, not a healthcare system. With greater emphasis on preventive care, the burden on the hospital system could be reduced. Yes, in Canada, healthcare is a right, but with every right comes a responsibility. Canadians should be encouraged to maintain physical health, emotional health, and nutritional health as a personal and collective responsibility. Without victim blaming, can we rely solely on repairing the damage we do to our health by ignoring all the public health advice?
How can specific issues be addressed?
Electronic health records that include information from pharmacies, diagnostic testing, physicians’ visits and institutional care are fundamental to informed decisions about the patient’s history and requirements. These do not exist at present. A timeline to implement this should be established, funded, and followed.
Physicians and hospitals are likely to work in silos of their own hospitals, medical school groups and communities. There is a movement underway to create databases of timeslots for specific surgeries, e.g., cataracts and hip replacements. This could allow referring physicians to find the shortest waitlist that accommodates the patient’s needs and filters such as distance. We cannot afford to ignore such innovations and we should not expect physicians to take on the establishment of such databases on their own.
Staffing issues for family practitioners and specialists could be addressed by implementing a better system for foreign-trained doctors to gain accreditation in Canada. This issue has been on the slow, back burner for decades. It is only one part of the doctor shortage solution, but it should be remembered that other countries need their physicians as much as Canada might want to recruit them.
Staffing issues for physicians could also be helped by considering other professional groups that could take some of the workload off doctors. One example is reducing the administrative load on physicians, who currently spend a significant portion of time during patient visits working on laptops. With advances in computer technology, and those of AI, is there a better way to capture the information? How could this tie into the issue of a comprehensive electronic medical record?
What about increasing the scope of practice of physician assistants, nurse practitioners and pharmacists, among others? This is happening, albeit slowly, in some provinces, but the role of physicians is still considered the benchmark of providing patient care services.
What about other professionals, such as midwives, doulas, osteopathic physicians (we have a total of 20 in all of Canada), physiotherapists, occupational and respiratory therapists who work in home settings? As long as Canada continues to see physicians and hospitals as the apex of the healthcare system, such healthcare professionals will continue to be underutilized, underfunded and undervalued.
Is there a best-case scenario?
In an ideal world, when a patient is diagnosed with a serious condition, the first step would be to discuss the severity of the case in order to match it with the resources required to treat them. Could home care or visiting nurses provide what is needed? What about a specialist’s office, or community-based healthcare centre? A group practice offering more than basic health care? Is there a role for private services in Canada?
Sometimes, only a hospital can match the patient’s needs, either because of the complexity of the problem or because of other healthcare issues facing the patient. In the best-case scenario, the patient is quickly referred to a treatment centre. Before admission, the patient is screened and tested while still out of hospital. The treatment plan is discussed and explained for care before, during and after hospitalization. The patient’s family is part of the planning process.
Does this automatically lead to a hospital stay? No. Advances in technology and, especially, surgical techniques, mean that many procedures can now be done on a day-patient basis. Progress in pharmaceuticals similarly means that patients can come to a facility for drug regimens while they continue to live outside the hospital.
Ideally, the care, wherever provided, takes place within a reasonable period of time, as close to the patient’s home as possible. With fewer overnight stays, there are fewer hospital-based infections or complications and the patient is discharged home with a follow-up care clearly spelled out.
The reality is different from the ideal
As we all know, the reality can be quite different. Inadequate facilities and staffing are a major part of the problem. Relying on hospitals to provide care that could be provided elsewhere only serves to continue thinking that is past its prime.
Some professional organizations are once again trying to address these problems by approaching them with fresh ideas. New medical schools, for example, are turning to more apprentice-like learning experiences outside of classrooms and specialty hospitals. These schools are geared to northern and remote communities, acknowledging that advanced procedures and surgeries would require transporting the patient elsewhere.
Students learn in smaller communities, in smaller healthcare facilities, performing a variety of procedures under supervision, often within weeks of enrolment. They learn not only medicine but also the social aspects of the community. Such students tend to become family doctors who remain in the smaller and more remote communities.
Making the changes
In recent months, the federal government has agreed to $196 billion in additional healthcare funding over 10 years, including $46.2 billion in new money. There is a bottleneck that keeps the money from flowing. The provinces and territories have yet to create coordinated targets and timelines to show how the money will be used to improve access to care. This doesn’t help.
Also in recent months, the federal government reviewed Addressing Canada’s Health Workforce Crisis, prepared by the Canadian Medical Association, the Canadian Nurses Association and the Canadian Association of Family Practitioners. The report contains 41 recommendations; it is significant that each recommendation begins with “That the Government of Canada collaborate/work with the provinces, territories and (either professional regulatory bodies or Indigenous Peoples)…” – to accomplish the work.
The money is there and the recommendations are there to begin the huge overhaul of Canada’s healthcare system, including hospital resources. The number of hospital beds needed should ultimately reflect the implementation of the recommendations. It may increase, but it may also decrease. Political grandstanding on the part of provincial and territorial leaders is a major factor prohibiting the changes from beginning.
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