Crisis Or Crossroad: Towards a Consumer-Friendly Health-Care System

Head Table Guests

David Edmison, Past President, The Empire Club of Canada and Director, Martin, Lucas & Seagram Ltd.; Rev. Kent Doe, St. Bartholomew's Anglican Church, Regent Park; Meaghan Atherton, OAC Student, Monarch Park Collegiate Institute; Joseph de Mora, President and CEO, The Sudbury Regional Hospital; Carol Southcombe, Director, Health-Care Services, Glaxo Wellcome Inc.; Jennifer Bowman, Senior Manager, External Affairs, Glaxo Wellcome Inc.; Doris Grinspun, Executive Director, Registered Nurses Association of Ontario; and Bill Laidlaw, Third Vice-President, The Empire Club of Canada and Director, Government Relations, Glaxo Wellcome Inc.

Introduction by Gareth Seltzer

Mr. MacKinnon, on March 13, 1997, almost one year ago to the very day, you brought to The Empire Club of Canada your comments and those of your organisation, the Ontario Hospital Association, on the dramatic changes undertaken by the provincial government with respect to hospital restructuring and health care in Ontario. Unquestionably, you were well qualified to provide your insight as to the future of health-care services.

At that time, our President said that she hoped you would return to update us on this topic and we are delighted that you accepted our invitation to do so. We need to know whether our health-care system is in a palliative care mode, in critical condition, or are we soon to be, or have already been, upgraded to fair and improving. Whatever our condition, we need to act fast and thoughtfully. It reminds me of the story of a man who walks into his barber shop and says: "Just a quick shave please, I don't have time to listen to a haircut." At the same time, I understand that you are concerned--and I am sure we will hear those concerns today--that policy makers are in too much of a rush to transform the system.

Mr. MacKinnon brings more than 25 years of government and business experience to the Ontario Hospital Association and is the past president of Ortech, an applied research organisation. Having read his biography, I think it is fair to say, in the interests of time, it is very lengthy and very impressive. The OHA represents over 23,000 Ontario physicians and I am sure has been well represented by you as President.

Please join me in welcoming the President of the Ontario Hospital Association, Mr. David MacKinnon.

David MacKinnon

Thank you for that introduction, Gareth, and good afternoon.

I am glad to be here again.

I want to emphasise, at the start of my remarks, that I'm going to talk about issues of very long standing. When one makes remarks of the type I'm going to make today, one runs the risk of appearing partisan or of being unduly critical of people or governments currently in office. I don't mean that at all.

From long personal experience with the Ontario government, I know that the problems I'm talking about and the administrative issues relating to them go back as long as 30 years. One has to have real empathy for any government or person who must deal with problems that are so deeply rooted and that have endured over so many different administrations.

However, more than ever, the people of Ontario are troubled by what they see as deepening problems in our health-care system. They are losing confidence in its responsiveness and are worried about its financial stability.

Today I would like to talk about how we can turn these problems into a crossroad and how we can take a very different path to the future.

Exciting new ideas are sweeping through our industry which we think will help us transform our service to the consumer, bring stability to the system and restore public confidence.

Let me first talk about what has taken place in health care during the past 12 months. When I spoke here in 1997, the situation we faced was potentially disastrous. We were facing a third year of budget cuts of unprecedented proportions which we could not have made while preserving medicare as we know it.

There was no budget at all for the major costs associated with restructuring hospitals. Boards were overburdened. Staff morale was at an all time low and nurses, the heart of Ontario's hospital system, felt especially overwhelmed. There was every possibility of a real disaster in the Ontario public hospital system.

Fortunately, the government listened to the advice we presented. In its budget of last May, it postponed the planned third year of cuts to hospital budgets. And it also provided for restructuring costs. These two decisions meant we had some breathing room to work our way out of the difficulties we faced.

I should say how much we value the help provided to us to present better and more detailed advice to the government. The CIBC, in particular, has been wonderfully supportive in terms of lending us expertise, and we could not have done it without them.

Despite this progress, I would not want to mislead you and say that we are on stable ground, even though we have been using our limited breathing room to maximum advantage. We haven't yet reached the kind of stability we want.

Staff morale, which is so crucial in hospitals where the highest standards of quality must be maintained, is a real worry. The clinical and budget targets of the Health Services Restructuring Commission have proven to be unrealistic and out of phase with the actual circumstances of most hospitals and must be constantly refined. Public concerns have grown, fuelled in part by media stories about the many stresses and strains on the system. More and more hospitals are looking at red ink as they struggle to cope with rising service demands.

The failure to build new long-term-care beds over the last 10 years has come home to haunt us. We have no place to discharge patients who have completed the acute phase of their illness and now require other, more appropriate levels of care. As a result, hospitals all across Ontario have less capacity to admit emergency and urgent-care patients. The result? Patients in hallways.

I want to assure you that we are tackling all of these issues in every practical way. But a heavy price is being paid in terms of public opinion.

How people feel about their health-care system should matter very much in any discussion about health policy changes. That's why OHA does a substantial amount of polling. As well, hospitals do surveys of their consumers. And, of course, one can interpret much from public comment in the media. Based on all this, we know that of all the issues on the public agenda, the issues facing hospitals and health care are the most significant to the public.

People believe that the dramatic changes being made to health care are being made to cut costs. They don't believe the message of governments across the country that the changes are about improving quality. The public in Ontario also believes by a large majority, that health care will worsen over the next year. Fully 92 per cent are deeply concerned about health care in general.

Women are much more concerned about health care and hospitals than are men, in part because they are the principal caregivers. It should not be forgotten that about 60 per cent of the people who use hospitals are women; the vast majority of the people who work in them are women and, last but not least, the people who bear increased burdens as care is shifted back to the family--for that is what the shift to the so-called community means--are women.

This shift of services from institutions to what is described as the community is, in fact, at the heart of current problems in health care, and I'd like to explore it further.

Since the early 1980s, this shift has been the dominant public health policy in Ontario. It has become accepted gospel that the shift to the community--we should really say the family--will produce a better combination of price and quality than institutional care. This generalisation has taken deep root and successive ministers of health have worked to shift resources from institutions to literally dozens of other providers.

The trouble is that the generalisation that it is either better or cheaper to shift health care to the community has no validity. Take home care, for example. We've looked at studies the world over and the reality is that different levels of home care have different price tags and different definitions. Some can be more cost-effective than institutional care and some can be much less.

The evidence is absolutely clear--no overall generalisation is possible on which is more cost-effective. It is even possible that quality could decrease and costs rise rather than the other way around if we persist with the shifts from one provider to another that are underway in Ontario.

There is, in fact, a school of thought well illustrated by a recent study done by Ontario's Institute for Clinical and Evaluative Studies that says that home care cannot be viewed as a substitute for institutional care at all.

In brief, there is a place for institutional care and there is a place--a very important place--for home care. What there isn't is enough evidence to support the destabilisation of one part of the system to find the funds to enhance support for the other. Other jurisdictions, notably Saskatchewan, are making major efforts to find out what the facts are. We should do the same and until we get the facts we should not indulge in major financial shifts within the health-care envelope.

This issue is absolutely pivotal. Taxpayers may well wonder what all the fuss is about in health care given the overall stability of the health-care budget. Here is the answer. One of the most important collections of medical skills and assets in the continent has been destabilised over a long period of time to support allocation policies for which there is very little evidence.

There is a special reason why we should be careful now to be sure we get the evidence to support what we are doing.

It lies in the fact that we have a precedent--a very significant one--from a few years ago when we de-institutionalised the mentally ill.

I have been searching for the kind of eloquence necessary to describe the consequences of our effort to move the mentally ill from institutions to the community and found my words to be lacking. They are too clinical, too cold, too impersonal. Fortunately, someone has helped. I'd like to read from an article by Michael Valpy in the Globe and Mail last Saturday: "Deinstitutionalising of the mentally ill, an Age of Aquarius event that dawned across North America and Western Europe in the rosy sixties, has gone down a road no one foresaw."

In his column Mr. Valpy goes on to quote Dr. Sam Malcomson, Chief of Forensic Services at Toronto's Queen Street Mental Health Centre. Dr. Malcomson says, "The Criminal Code has become the Mental Health Act of the 1990s."

Valpy continues:

"With the closing of hospital beds, the new institutional addresses for the mentally disturbed and visibly disoriented are inexorably becoming the jails, the homeless hostels and the streets.

"It is not a new story, merely one that in the past few years has become horribly stark.

"There are accounts of desperate families with no one to turn to for help except the police for their potentially dangerous, delusional children and siblings and spouses.

..."a rash of subway-shoving incidents and seemingly random public assaults.

..."police with no option but to take menacingly ill people to jails.

..."courts and administrative boards whose orders to admit people to mental hospitals are routinely ignored." Are we going to do this again? Perhaps for other illnesses? Do we want our children, 20 years from now, blaming us if we do? Especially if we proceed in the face of the clear precedent we have before us?

I hope not, for nothing debases our civil society more than carelessness in dealing with those who are ill, or carelessness in dealing with those who are responsible for people who are ill.

Here I would caution that shifting services and funding from hospitals to the community means that we're pushing a greater burden of responsibility back on to families--both in terms of effort, and, in many cases, out-of-pocket expenses. Why has no one asked consumers what they want and can support in the way of personal time and resources to care for family and friends without the help that is available from hospitals?

The situation we find ourselves in today did not develop overnight. It's taken us many years to get to this current state of conflict, impaired system performance, deteriorating public confidence and chronic budgetary difficulties. And, as I said earlier, one clearly must have sympathy for political leaders who happen to be in office when the music stops.

In any event, something needs to be done if we are to prevent further erosion in health care. While change is needed, what we don't need is a radical and revolutionary overhaul of the system that could end up creating further instability. We do need to focus on practical solutions, where decision making is evidence-based, and where change is evolutionary. Rather than attempting to build new systems from the ground up, we must recognise and build on the strengths of the existing system.

In particular, if our goal is to integrate services and create a more consumer-friendly and cost-effective system, we should seek to reinforce the positive developments already taking place in this direction in our current system. We should recognise and follow the example of those who have already demonstrated leadership.

Fortunately, there are many positive developments already well underway. OHA recently commissioned a study on how hospitals are changing to better serve their communities. What we learned is that in many parts of Ontario hospitals have evolved into what you might call broadly structured Health Care Centres. They deliver a wide range of health services, many specifically aimed at avoiding illnesses, usually in alliance with other providers. For the consumer, this translates into access to a broad range of comprehensive health services, with minimal service disruptions.

This is happening all over Ontario--in rural communities as well as in urban and suburban settings. You can find examples of this in single hospital communities in Nipigon and Parry Sound and many others. In each case, consumers access a full range of services through the hospital and the partnerships it has developed. The hospital has become the umbrella under which health services are provided to the community. And because of its expanded role, the hospital is able to manage a patient's care most effectively by intervening at the appropriate level, thereby reducing the number of patients who need to move on to higher--and more costly--levels of care. In each of these cases, the hospital has become much more than just a traditional hospital.

Another example is the Central Metro Integrated Health Delivery Network, of which Sunnybrook Health Sciences Centre is a leading member. This network includes over 30 organisations--hospitals, home care organisations and meals on wheels. Many health-promotion organisations are very important supporters of this network, as well as large private corporations such as IBM and Bell Sygma.

All across Ontario, the future shape of health care is taking place before our eyes. Probably 30 or 40 hospitals are becoming broadly structured health enterprises--a major transformation. And in the rest of the system the evolutionary path is clear: It is to move forward to provide integrated and user-friendly health services, almost always through alliances of all types with other providers. It is very exciting to see this happen.

However, if the present pace of evolution continues, it could be 10 years before all Ontario citizens benefit from this remarkable transition in what a hospital is. We think it can and should happen much faster.

We have taken concrete steps to make sure it does. Recently, OHA submitted a detailed proposal to the Ontario government encouraging it to recognise this evolution, to celebrate it and to adopt funding and regulatory arrangements to support it. We have made it clear to government that hospitals are ready to broaden the skills and expertise on their boards to accommodate other providers and will operate in a genuine spirit of partnership.

Think of how much stronger the health-care system would be if we had these new Health Care Centres in place across the province offering a broad range of services.

• Consumers would be assured of access to a full range of services;

• Health providers would be in a better position to intervene at the earliest or most appropriate stage; • We would avoid the costly disruptions associated with making significant shifts within different areas of the health sector;

• Care would improve greatly because different levels and types of care would be integrated; and, finally

• Administrative costs would be reduced since we would be spreading the overheads over one organisation.

As I've said, many hospitals have already been working to turn themselves into more broadly structured Health Care Centres.

We are now asking the government:

• to demonstrate its commitment to this approach;

• to implement supportive legislative and regulatory changes;

• to establish criteria for selecting and evaluating integration proposals from rural, suburban and urban areas; and, finally, and most importantly,

• to fast-track the best proposals that come forward.

We are moving in other new directions as well. We believe that entry to a hospital's services, or indeed the services of all providers must be more than just its front doors.

That gateway should be, in part, electronic. If we had effective telephone triage services in place in every hospital today and for the province as a whole, I guarantee our emergency-room problem would be much improved. Similarly, we need the Hospital of the Internet to help our customers inform and educate themselves--and we need it now. We are energetically working on both of these initiatives and I think you'll see evidence of our work by the end of the year. We have practical working examples in other provinces, notably New Brunswick, and we intend to be shameless imitators so that in a year or two we're back where the Ontario health-care system should be--in the forefront of events and staying there. At our last annual general meeting, OHA's member hospitals adopted a broad programme which includes these two measures--telephone triage and the Hospital of the Internet--and also involves better public reporting, an enhanced focus on advanced research, and the further evolution of hospitals as health centres, along the lines of the suggestion I made a few moments ago. We are optimistic that the government will work with us on these initiatives, but if it doesn't, we'll do what we can on our own.

In summary, Mr. Chairman, hospitals have had a very, very difficult year, but we are doing all we can to minimise the negative impact on consumers and we are moving forward. To succeed, hospitals need to make basic changes themselves and they need a fundamental change in government policy.

As a society, we must plan and build the system on the evidence available to us and not on well-meaning beliefs. Over the next year or two we must use existing best practices as the basis from which to build a new network of Health Care Centres in Ontario. If we take these two steps, we will see a much improved system and the present stresses will become a distant memory.

Thank you.

The appreciation of the meeting was expressed by Bill Laidlaw, Third Vice-President, The Empire Club of Canada and Director, Government Relations, Glaxo Wellcome Inc.