How Many Hospitals?

Posted June 10, 2016

The main feature of the Auditor General’s (AG) report this week was its examination of Nova Scotia’s Hospital System Capacity.

The auditors’ primary source of information was interviews with management of 19 of the province’s 41 hospitals. So anyone who has followed previous reports—and the constant struggle to keep expenses under control—will find the main conclusions unsurprising.

That is not to say that the auditors just repeated what management told them. They conducted various tests to ensure that what they heard was consistent with other sources of information and their own observations.

The core message is that the system is not sustainable using historical methods of delivering care. This conclusion is informed by four salient findings.

  1. It is not just the Victoria General that has serious maintenance issues. Much of the infrastructure elsewhere is in disrepair—balky elevators, leaky roofs, deteriorating brickwork. Some hospitals lack sprinkler systems or adequate heating and ventilation. Available funding ($29 million) is nowhere near enough to complete urgently needed infrastructure repairs and maintenance ($114 million).
  2. Many of the services that are delivered in a hospital setting could be delivered more cost effectively in other settings. Emergency rooms are an expensive backup when a family physician is not available. Patients who need to be admitted linger in the emergency room, while inpatient beds are tied up by others who could be better served at home or in long term care facilities
  3. Some capabilities are under-employed. Several hospitals maintaining 24 hour emergency service report one or fewer patients per night—a tremendous waste of human resources. The new Colchester East Health Centre has far more capacity for surgical services than is needed for the former region’s population.
  4. We have hospitals, some needing major repairs, located very close to other hospitals. There are three community hospitals within 30 minutes of the Cape Breton Regional Hospital in Sydney. Fisherman’s Memorial Hospital is located 20 minutes from South Shore Regional Hospital.

All of this would seem to make a compelling case for reducing the number of hospitals. The report comes very close to saying as much: “The large funding gap makes it clear that the… system cannot reasonably sustain all of its current facilities.”

But it not as simple as just shutting some of them down. The three community hospitals in Cape Breton are almost fully employed. Those patients need alternatives.

The four issues described by the Auditor General have to be tackled together and, for that to happen, Nova Scotians are going to have to change some of our cherished beliefs. This is territory the AG did not enter.

  1. Everyone should have a family physician. About 10% of us do not, which is comparable to the Canadian average. But this formula often fails to work even for those who do, particularly in rural areas. The doctor can be sick, on vacation, overbooked, or just retired. An isolated family practice is far from ideal for the doctor—she or he has no one to turn to for a second opinion, or help with a surge of patients in flu season.

    The right goal is that everyone should have timely access to primary care. This is accomplished by the collaborative emergency centres which include a variety of health professionals. The care can be both more appropriate and more cost-effective. Walk-in clinics are a second choice, especially in the near term. In either case, patients will sometimes face a longer drive.
  2. The government can provide all of the essential care services we need. This has never been true. Pharmaceuticals, ambulances, physiotherapy, and other services are not publicly funded outside the hospital environment.

    The way our single-payer system controls cost is by limiting supply. We do not have waiting lists for hip and knee replacements because of a national shortage of orthopaedic surgeons.

    The question is not how we can find even more money to deliver services. Rather, it is how we can deliver as much quality care as possible within the currently available funding.
  3. We should not need to travel further than the nearest regional hospital for most services. It is expensive to have surgical teams dividing their time between different venues. Concentrating services in fewer locations will allow for greater collaboration between teams, and locating work in underemployed facilities.

    Some of the work currently done at the leaky Victoria General can be better done in the available space in Truro. That will be more convenient for people in northern Nova Scotia, and not a big addition to rush hour commute time for people in many parts of Halifax.
  4. Once a patient is admitted to hospital, she or he should remain there until fully recovered. It is both more cost-effective and in the best interests of patients (who often receive better care in these circumstances) to move home or to long term care facilities as soon as possible after procedures to treat their condition.
  5. Patients should not be allowed to pay themselves for care outside the public system. The issue is usually not a shortage of doctors or nurses—it is the availability of funding. Patients are not prevented from going to Boston to get a hip replacement. Why would we prevent them from paying for treatment at a private facility say, in Bedford, keeping the economic activity in the province and shortening the waiting list in the public system?

One of the advantages of the province-wide health authority is that patients can be directed to the best and most efficient resource. We only have so much money to spend. We have to make the most of every dollar.

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Most Recent Comments

  • Collaborative Care Centres are for Primary Care , and are not part of Emergency Centres. Important to keep the language simple and clear
    I appreciate your writings Bill
    I trust that you read Dr Martel’s recent article and my brief opinion piece
    All of our efforts are really important. The Health System so needs strategic leadership.

    Ruby. Blois | June 18, 2016

  • I think the comment by Mr. Wedge puts focus on the real issue. There are too many academics involved in the discussion, and terminology abounds.
    Who cares if it is called primary care, Collaborative Emergency Center, a special classification of emergency, walk in clinic, and so on. A citizen who needs immediate health care wants their needs to be taken care of effectively, efficiently and quickly. Regardless of the Terminology applied to the facility used, the current system is an absolute failure. And it does not need to be.
    Lets forget the academic theories and the terminology, and start to apply some common sense. Most of the failings have been known for 30 years, whether it be family doctors, shortage of long term care facilities, unhealthy hospitals.
    Academic and terminology arguments have gotten us nowhere. Time to try good old fashion common sense.
    Politicians argue about rules for assisted dying. Meanwhile they accept the existence of facilities, or lack of, that have contributed to deaths, whether the citizen wanted to die or not. Explain that contradiction!!!

    barry h | June 12, 2016

  • “The right goal is that everyone should have timely access to primary care. This is accomplished by the collaborative emergency centres which include a variety of health professionals.”

    Overall, I would say this pice offers good insights and potential solutions to the healthcare issues in Nova Scotia, but this particular quote is plainly incorrect. Collaborative Emergency Centres are not primary care, and do not contribute to continuity of care. That doesn’t mean we shouldn’t have Collaborative Emergency Centres, but we shouldn’t confuse them for what they truly are: a special classification of emergency care services. As-is, a CEC is a walk-in clinic without a doctor on site.

    The solution needed for primary care is a collaborative practice model where physicians, nurse practitioners, and other health professionals work side-by-side to treat patients, with multiple physicians in the care group. Using Open Access scheduling they can ensure timely access to care, with patients typically requiring three days or fewer to get an appointment. The typical low-acuity patients arriving at the current Collaborative Emergency Centres are willing to wait up to a week for an appointment before attending emergency care. The issue is that physicians, working alone, and using a fixed appointment model, cannot respond quickly to patient demand. As you correctly point out, vacations wreak havoc on appointment wait times in rural practice settings.

    For more on the trade-offs of CECs, see the literature review section of my master’s thesis: https://dalspace.library.dal.ca/handle/10222/71506

    Ben Wedge | June 12, 2016

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