Smaller Might Be Better

Posted February 22, 2013

The time has come for more special purpose clinics in Nova Scotia. Waiting times for many procedures are too long. Special purpose facilities like Scotia Surgery can be a bigger part of the solution.

The Canadian benchmark for hip and knee replacements is to have the procedures completed within 182 days. In Nova Scotia, the most recent statistics show only 63% of hips and 41% of knees are done within that timeframe. One in ten hips are still not done after 472 days; one in ten knees are still waiting after 542 days. Similar results can be found in other specialties.

The problem is not a national shortage of surgeons. There are several dozen unemployed orthopaedic specialists in Canada. The problem is a shortage of money, as a result of recent government restraint.

It is increasingly clear here and in other provinces that the Canadian benchmarks are aspirations, not promises. How close we get to them will depend on how cost-effectively we deploy limited financial resources.

One small but novel experiment is the use of Scotia Surgery to do outpatient surgeries (rather less complicated than replacements) on hips and knees. Scotia Surgery is a private facility in Dartmouth. It hosts the same surgeons who work at Capital Health facilities but provides the space and ancillary staff. It benefits from smaller size, narrower focus, flexible staffing, and less expensive real estate.

It is encouraging that the Minister has acknowledged the cost savings and can be expected to renew the contract.

At the same time Capital Health is examining its physical plant and is expected to propose new building programs costing in the hundreds of millions of dollars.

Before taking that route, we should use the opportunity to experiment with smaller, specialized facilities for a variety of procedures. Candidates might include hip and knee replacements, ophthalmology, most plastic surgery, and diagnostic imaging. Inpatient surgery for patients without complications should be possible.

The facilities could be either public or private. What matters is that energetic and flexible staffs are committed to maximizing efficiency. Faster care is better care. With limited budgets improved productivity, this is the only way to get there.

These are experiments, so rented facilities are more appropriate, and quicker to access, than new construction. Suburban office parks may represent a good opportunity, being more convenient for families and staff, and more accessible for out-of-town patients.

Would retaining programs within the walls of the Victoria General and Infirmary, getting advantages in size for services such as food, cleaning, and laundry, be expected to provide a better result? Perhaps not. Anyone who has flown through London Heathrow or Chicago O’Hare can testify that very large airports are not very efficient.

Any efforts to allow experiments can expect shrill resistance on two fronts. Union leaders, already disliking the Scotia Surgery example, will be unhappy with the prospect of facilities that they do not control through existing collective agreements, particularly if those facilities produce superior results.

Others will assert that the proposed arrangements violate the Canada Health Act. This can hardly be true. Otherwise, Scotia Surgery would not exist, let alone the Shouldice Clinic in Ontario.

Founded in 1945, it is a global centre of excellence in hernia repair and takes both publicly insured Canadians and uninsured out-of-country patients. Past patients include Jack Layton and Joe Clark.

Wouldn’t it be nice if we could replace long wait times with a global centre of excellence in knee and hip replacements, at the same cost?

Not every experiment will succeed, and our aging core facilities will still need renewal in order to adequately treat the patients with the most complex or severe conditions.

But this is an ideal time to try new ideas, before we commit hundreds of millions of dollars we don’t have to new large facilities. The Minister has acknowledged the benefits of different approaches. We should do more.

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  • REPLY TO DAVID:
    If the small centers don’t save money they should be closed. If they do then the experiment should be expanded. Either way it is the government that will deal with the finances. There is no suggestion in the article that patients would be charged.

    Bill Black

    Bill | July 2, 2013

  • There is no doubt Mr. Black that this kind of healthcare delivery would help make those services more accessible but what you are failing to point out is that these services would come at a premium cost to the users of such services and that these costs will not be cheap! Isn’t it true that this kind of capitalistic healthcare structure is tailored toward the wealthy and does nothing for the poor!? Or will you deny that!?

    David | July 2, 2013

  • Another point you made in your article regarding “less expensive real estate” also makes perfect sense. I am sure there are buildings in Bayers Lake Park that could be set up as auxiliary pods for certain Specialities. The convenience to patients and their families getting there would be a plus. There is no real reason why hospitals must stay in the south end of Halifax. The hospitals in Saint John and in Fredericton are not sitting in residential areas, nor do they need to be there. Every month, it seems, there are more leaks and flooded floors in the former Nurses’ Residence, part of the VG complex in the City–with staff again unable to work there and in many cases, again, sent home. The buildings that make up the old V.G. site are crumbling dumps (missing ceiling tiles, mould, leaking pipes, drafty windows, water often unfit even for bathing, dirty surroundings) all appear less than conducive to patients’ wellbeing and recovery prospects. These unhealthy places are less than ideal, as well, for all staff who work there.

    One person who left a comment described a Capital Health ‘Mis’management Team. It does appear that we have a Provincial Government suffering from inertia–while the waitlists grow longer and longer.
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    Please show first name only.

    Carol | March 11, 2013

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