Swallowing the Bitter Pill

Introduction:

Honoured guests, Head Table guests, members of The Empire Club. It is my great pleasure to introduce our guest speaker today.

The Hospital for Sick Children is a health care community dedicated to excellence in the compassionate care of children and their families. And behind every well crafted word of the Mission Statement for the hospital, known lovingly around the world simply as "Sick Kids", there is the thoughtful, careful, co-operative planning of David Martin.

Here is a man who accepted the challenge to change a hospital then $8 million in debt, planning for $12 million the next year-a hospital staggered and hurt by the worst kind of tragedy. A hospital reeling from exhaustive and microscopic public examination. Part of the reason for his hiring was, according to Chairman Allan Beattie, his "...broad overview, combined with passion and warmth".

To recite his virtues, as seen by his colleagues, is to invite the comment that, "only his mother would believe them all". His staff says, "He hides his ego in his pocket, so you don't even see it". And the Canadian Council of Hospital Accreditation carries the plaudits across the country. They say: "This is a superb hospital, unique in Canada and one of the best children's hospitals in the world".

But how do we keep our hospitals and our health care where they are today? David Martin's answer is in his address to us: "Swallowing the Bitter Pill".

Ladies and gentlemen, I am proud to welcome the President and Chief Executive Officer of the Hospital for Sick Children, David Martin.

David Martin:

I want to thank The Empire Club for the opportunity to discuss some of the challenges facing The Hospital for Sick Children and the health care system in the years ahead. I have titled this address "Swallowing the Bitter Pill". I plan to describe some of the problems currently facing us and then the capacity of the current funding system. But, of course, I wouldn't miss the opportunity to tell you about a few of the exciting things happening at The Hospital for Sick Children.

As Canada marks the 30th anniversary of the adoption of universal health care, we can be proud of a health care system that has been one of the finest in the world. Indeed, surveys repeatedly indicate that Ontarians and Canadians have a high level of satisfaction with their health care system, although a recent survey indicated some deterioration. Certainly it has many strengths. No one in this country is denied medical care for lack of money. We have a system of universal access that is, in my opinion, clearly superior to that of many other health systems. Further, Canadian researchers have contributed enormously to the advancement of medical research. These accomplishments have been possible only because we have encouraged excellence, and have provided the resources to make it possible.

The Hospital for Sick Children can offer testimony to public support for health care. We have been the beneficiary of enormous generosity on the part of the people and corporations of the Metropolitan Toronto area and beyond. Your support is making possible the construction of our new patient care centre, which will be the most advanced paediatric care facility in Canada when it opens in 1992. Almost half of the $220 million needed for the new facility has been provided by the Government of Ontario; $65 million will come from bequests, and the public campaign has raised more than $50 million. We are grateful to all who have contributed to this effort. The new facility will allow us to treat our patients more effectively, and accommodate them more comfortably.

It is vital to our patients that the parent-child relationship be maintained. If you are a parent, you know that this can be a difficult task when a child is ill. And if you are from outside Metropolitan Toronto--which 50 percent of our patients are--the problem of finding reasonably-priced accommodation makes it even more difficult. On any given night at The Hospital for Sick Children, more than 150 parents can be found sleeping in lounges, or on cots squeezed in between cribs. In the new Centre, most children's rooms will be private--designed to allow the parent to stay overnight to comfort, , reassure and help look after the child. We have also constructed a 75 room hostel for parents whose children are receiving care.

Another exciting development at Sick Kids Hospital is in the area of research. The Research Institute announced recently the landmark achievement of our research team in the area of cystic fibrosis, identifying the gene and its defect that causes the disease in 70 percent of the cases. The challenge was to find the genetic defect, which turned out to be three defective bits in a genetic chain of three billion.

This discovery and the method used constitute one of the most significant achievements in the history of genetics. The method used to locate the defective gene will provide the/ opportunity for researchers around the world to identify the genes causing other genetic diseases, of which there are morel than 4,000. It could lead to gene manipulation and drug therapy that will allow us to make countless genetic diseases things of the past. This is the challenge ahead! Obviously, we are very proud of the accomplishment of our genetic research, which has also identified the gene that causes Duchenne muscular dystrophy. But we also have to keep in mind how far we have to go in the area of research.

In that context, I'm reminded of something that a member of a prominent transplant team told me recently.

He told me that "at the present time, our transplant programs are at a comparable state to the medical practices that prevailed when Louis Pasteur was attempting to get the medical profession to recognize the need for sterilization". In other words, we are only at the beginning in this new medical adventure. Where it will take us, and the costs, are unknown. It would be impossible to calculate, for example, the exact cost of the research that led to the discovery of the cystic fibrosis gene. That project changed course several times over the past 18 years. It would be impossible to predict with precision the course of medical research over the next 18 years, in genetics, transplantation, or other vital areas. The one thing we can predict with certainty is that the cost will be enormous.

In hospitals across the world, extraordinary technological innovations have given us the tools for better and more accurate diagnosis and for safer and less invasive surgery. We have shortened hospital stays and lowered the death rate and the severe consequences of illness. Finally, technology has allowed us to improve the quality of life for our patients once treatment is completed.

Fifty-one years ago, the late Dr. Robert Gross performed the first heart operation at Boston Children's Hospital. That first procedure involved closing the connection between the major vessels leaving the heart. It was a great step forward. For 48 years this procedure was widely used. It involved making an incision the entire width of the left chest, two hours on the operating table, and at least 'five to seven days of convalescence in the hospital. For the past three years, however, with improved technology, the child can be out of the hospital within 24 hours, moving full speed ahead and without a scar.

Consider another example of the value of technology. Suppose your two-day-old baby is rushed to the hospital, literally blue because a severe narrowing of the valve between the heart and the lungs is inhibiting the flow of blood. Until 1985, the only option was to perform heart surgery in order to open that very narrow valve. Twenty to thirty percent did not survive the surgery. Today, your newborn would be home in five to seven days and the older child perhaps the next day. Neither would have seen the inside of the operating room. Using a catheter inserted through a vein in the baby's leg, the cardiologist can inflate a balloon, dilate and open the congenitally narrowed valve. This technique can be used thanks to the excellent imaging of the heart by a cardiac catheterization lab.

These are some of the things technology can do for us. But while technological development in the medical field is galloping ahead, here in Canada we're not keeping pace. One of the relatively new devices is the lithotripter used to break up kidney stones. Instead of an operation, shock waves are passed through the patient for 45 minutes to shatter the stones. In most large cities in the United States there is at least one hospital with a lithotripter. In all of Ontario, we have only one, with a waiting list now of many months. There are more nuclear Magnetic Resonance Imaging machines in the State of Michigan than there are in all of Canada. In Metropolitan Toronto, there are only two MRI's, which are invaluable for diagnostic purposes. The MRI's we have in the city are booked months ahead. At The Hospital For Sick Children, with the largest paediatric neurosurgery program in North America, we have access to MRI facilities one-and-a-half days per week. Children who are outpatients must now face a five to six month wait for an MRI scan. We've recently concluded an agreement to send children who cannot wait for access here to Buffalo Children's Hospital, which has access to three scanners to service a much smaller patient load. Some would argue that it is wise to let others try new technology first, until it has been demonstrated that it is efficient and cost-effective. But lithotripters were first introduced in 1983 and MRI's have been on the market since 1980. I would say they have passed their trial period.

The long lines waiting for treatment aren't just because of a shortage of technology. The waiting lists for high-cost surgery like a coronary by-pass finally hit the front page last December, when Charles Coleman died after his heart operation was postponed 11 times. Mr. Coleman's case made headlines because he died, but his long wait for a heart operation wasn't unique. At Sick Kids we have--I regret to report--many children on waiting lists for surgery of all kinds. The waits can be extensive.

The bottom line is that quality health care has a price--and that price is going up. One of the major factors driving it up is the technology that I have discussed. Like generations before us, we cannot even begin to fathom what high technology of tomorrow will offer--but we do have an idea of what it will cost. For example, the cardiac catheterization lab I mentioned has a price of $1.5 million. The Hospital For Sick Children was fortunate to receive our lab as a donation from the Variety Club of Ontario, Tent 28. But you and I know that donations like that don't fall out of the sky every day.

Medical research and technology are not the only factors driving up the cost of health care. We have an aging population--and it is a fact of life that the older you get, the more medical care you need. About 10 percent of Ontario's population is over the age of 65, and they consume 40 percent of our health care dollars. Early in the next century, that age group will be twice that large. What impact will that have on our health care services?

And then there is the issue of expectation. Because our system has been so very good, Canadians expect to have almost immediate access to facilities and specialists. They expect the treatment to be the very best available anywhere. Please understand that my colleagues--the doctors, nurses, physiotherapists, social workers, the whole range of health care professionals--also want to give them that access and that first-rate treatment. When they can't, they're angry and frustrated. In other words, there is expectation on both sides--and that expectation has been fostered because this health care system has worked! Are we now willing to settle for less?

Now we face another dilemma: a world-wide shortage of nurses. That has become the Achilles heel of many hospitals, including Sick Kids. The situation is simple to explain: you cannot put a person in the hospital if there is no nurse to care for him. Right now we don't have enough nurses to fully staff our operating rooms or intensive care units. As a result, we have closed three of our 14 operating rooms. Each surgeon has had his allocation of time in the operating room reduced by 22 percent. This means that waiting lists for surgery are again increasing. Young women today have little interest in the typical female occupations that provide minimal opportunity for personal or economic advancement. The situation is exacerbated in Toronto where the cost of living and cost of housing are so high that it even reduces our ability to recruit physicians.

Consider the fact that a nurse in our highest intensity units with more than 10 years' experience is still expected to work the night shift for a premium of just 45 cents an hour, and has reached the top of her wage scale at $38,000 a year. Contrast this to the North York School Board that recently signed a two year agreement which moves the maximum for a classroom teacher to $61,000 plus a cost-of-living adjustment with enormously better benefits and no shifts. At The Hospital For Sick Children we have developed dozens of initiatives to improve growth opportunities and working conditions for nurses. But they haven't solved the problem, and it will not be easily solved. Among other things, it will require a great deal of money for nurse training and higher salaries, particularly for those working in downtown Toronto. And it's not just nurses who are in short supply, but other health care professionals as well: pharmacists, physiotherapists, child care workers ... even paediatricians!

The question is: How are we going to meet all of these increasing costs? And can we expect the money to come from the taxpayers? Ten years ago, the Ontario government spent a quarter of its budget on health care--less than $4 billion. Today, the Ontario government spends about one-third of its budget on health care--$12.7 billion. They have spent more than $1.4 million in the hour we have been in this room. Obviously, when expenditures grow faster than inflation, the provincial budget and the provincial economy, something has to give. The Provincial government has made it clear that it does not intend to increase continually--in real dollars--its funding for hospitals. I'll be frank with you. If I were Elinor Caplan, I would be working just as hard as she is to challenge the hospitals and health care system: Be more efficient! Do more with less! I am not here to criticize her efforts.

We are seeing major changes in the delivery of health care: hospital mergers, changing patterns of delivery, rationalization of resources. These changes will accelerate as we adapt to the new realities. Management must be better. Partially due to restraints, 2,200 beds, the equivalent of four large hospitals, were closed in Metro Toronto this past summer, the highest ever. One can predict the implications of this trend if it continues.

I agree with the government that the answer is not more funding from the public purse. For one thing, additional funding for hospitals decreases the amount available for the environment, education, social services and economic development--all of which play a vital role in ensuring a healthier population.

But if the funds are not going to come from government, where are they going to come from? How are we going to afford the machines that can save lives, and the resources to cut down long waiting lists?

How are we going to pay nurses enough to attract them to the profession--and to keep them at the bedside?

There is strong economic pressure on physicians to reduce patients' lengths of stay. Considerable progress has been made.

But how much emphasis do we want to place on that particular solution?

Hospitals are at a disadvantage in this age of efficiency and streamlined manufacturing. The human body still has its limits in terms of its ability to recover. Moreover, provision of care services are labour intensive and not easily automated. Certainly, the decision as to length of stay must be a medical one, based on medical reasons, not economic.

The Province is planning to create a more extensive network of community health facilities, to shift people away from large institutions. We see a role in this for our hospital--taking our experience and expertise into community-based clinics, just as we did 50 years ago.

Promotion of healthier lifestyles is now high on our public agenda.

But despite these measures people will continue to fall ill and be injured--and some will not adopt a healthier lifestyle. Preventive care and community care programs will not reduce the cost of providing quality care in hospitals.

Indeed, by shifting less complicated cases to outpatient treatment--as we have done--we increase the intensity of care for those who require a higher degree of specialization.

With most of the hospitals in this province in a difficult financial position after years of funding less than inflation, how are we going to be able to maintain the quality of care that the public expects? That is the bottom line.

The fact is, we may have to revisit an idea that many Canadians oppose--and that is, some private fee-for-service. I have concerns about it myself. I just can't see another solution out there.

Many will argue that a change such as this would be an incursion on the principle of equality of access.

But the fact is this: If we do not find a way for hospitals to obtain more resources, equal access to health care may soon mean equal access to longer waiting lines for the use of outdated equipment.

In Ontario--and across Canada--equality of health care is becoming a levelling of health care.

Are some people already paying extra for health care? We have had a large number of children whose surgery was delayed. This often was at very real expense to the families in lost wages; fruitless trips to Sick Kids, often from some distance; babysitters needlessly hired.

I won't attempt to describe the emotional cost to patients and their families when surgery is booked, cancelled, booked again and cancelled again--and then finally goes forward on the third attempt.

Ensuring access to quality, timely medical care--if that is what we want, if that is the will of the public--will cost more money. If significantly increased funding cannot come from the public purse, we must explore other sources.

Many of our patients tell us they would not object to a partial fee if it would allow us to provide speedier service, and maintain or improve the quality of care.

For politicians, the idea of co-payment is a bitter pill. But it may be one that has to be swallowed if we are to avoid something that would leave a far more bitter taste--a health care system that is unable to provide the quality of care people expect and need.

We do have choices. I would hope that we do not wait until the VIA Rail type solution is upon us.

Ladies and gentlemen, a few moments ago I pointed out that our system of health care is one of the best in the world. It is admired by many and has earned many laurels. But laurels are not something to rest on, they are something to build on.

We can build on the base we have established, and create a system that will constantly improve in its stability to help people live longer, healthier and fuller lives.

This is the goal we share. Achieving it will not be easy. We will have to make some tough choices.

And, we will have to make some courageous decisions. The time to start is now while these choices are still ours to make.

The appreciation of the meeting was expressed by Peter Hermant, President, Imperial Optical and a Past President of The Empire Club of Canada.