Ed. note: This article and its companion are written by two former hospital board chairs. The recommendations are primarily on issues that local hospitals and health systems can address without waiting for government and other agencies to move on.
Over the past dozen years, every health system in the Western world has moved from struggling with capacity issues to becoming nearly overwhelmed. This is no less true for Canada – and our shifting demographics to a more aged population. is exacerbating the capacity issue.
A 75-year-old conservatively consumes three to four times more health care than one under 50. Further complicating things is that seniors tend to be afflicted with a growing set of chronic and acute conditions as they age, leading to an increased dependence on specialist care. Those not quickly and accurately diagnosed and left unresolved become increasingly ill and create further pressure on the system.
This load will continue to ramp up for years to come. The majority of the baby boomers are just now turning 70. Life expectancy for this cohort is mid- to late-80s.
How bad is it? The Canadian Institute for Health Information (CIHI) has a host of data on wait times that can be studied at length. However, consider one simple illustrative metric that simply should not exist. It quantifies how many patients are admitted to non-standard accommodation, i.e., hallways, storage areas, etc. ERs are no different. This is not good medicine.
When the system is overloaded, all patients, regardless of age, become disadvantaged. While seniors may be particularly vulnerable, high wait times affect all.
Consider the example of one patient who ingested a common parasite. The patient presented primarily with gastrointestinal (GI) distress severe enough to prevent ingesting sufficient nutrition. Delays in diagnosis exacerbated the condition. The need to involve a GI specialist was readily apparent but despite the severity, specialist wait times were uncertain and stretched out months. In the meantime, in an effort to help, additional expensive and scarce resources were used. Indeed, the patient was told that to move his case forward to a specialist, surgery was required to rule out gall bladder despite the lack of compelling clinical evidence. The surgery was successful but failed to improve the patient’s condition. In addition, the patient needed multiple ED visits to help manage symptoms and a growing list of complications.
Not least among this resource consumption was the amount of time the primary care physician spent advocating on the patient’s behalf. This patient spent more than a year on this path before starting to recover and lost almost a third of their body weight. Money always comes up when discussing health care but additional funding will not, by itself, solve the capacity challenge. It is unwise to expect that the arrival of additional doctors, nurses and beds will alleviate the problems. At best, even if the government chose to fund this, it would take years for help to arrive. Substantive throughput improvements are required now and in the future.
So, what’s to be done? I believe the answer lies, at least in part, with local hospital administrations and their ability to optimize the system to increase throughput. To do so, the following is proposed.
1) Measure the volume requirement. Hospital administrations need to take a long, hard look to see what the needed load is. Today’s planning starts with the capacity the system can offer, not the need. The first pass undoubtedly will lead to an understanding of the unsettling gap between need and capacity. Deeper dives are required to understand the needs beyond just beds. I am concerned that the skills needed to do this “traffic” analysis are not routinely available in medicine. Fields outside of medicine know how to create demand models and, if necessary, should be employed.
Boards and hospital senior leadership need to demand this information and clear plans to deliver the needed capacity.
2) Identify and address the bottlenecks. Bottlenecks keeping patients from the expedient type of care (e.g., specialists) they need beyond the emergency department need to be unearthed
3) New models. Care models and clinical pathways need to be developed with specific emphasis on how specialists are accessed and supported. These need to recognize that simple one-ailment models will be insufficient to address the load, especially from the seniors’ population.
4) Diagnostic specialists. Develop the role of a specialist who can assess the most challenging patients via a broader look for misdiagnosis and unaddressed clinical interactions. Such a role would be a resource to all clinicians trying to treat challenging situations that don’t cleanly fit into an existing practice stream.
5) Flexible avenues for funding. During my time in governance, I saw no mechanism to get funds outside the preset budgets for improvements that could be justified with a return on investment and specified payback period. This was especially true of small improvements identified outside of the funding envelope and not in the budget cycle. Opportunities are being missed because of this. Hospitals need to be supported as they identify such cases.
All in all, this will be a tall ask of the current system. Some of these issues will be red hot politically. But serious capacity constraints are everywhere and the system is showing quality-of-care issues. The reality of our demographics means there is a pressing need for change now.
We believe that significant improvements can be achieved by local hospital administrations by better understanding the capacity needs in front of them and developing strategies to address them. Can it be done? I believe so. Look at the re-architecting of primary care that is underway in Ontario. It has been a formidable undertaking done by thousands of professionals. While there is still a shortfall in capacity, substantive progress has been made
If primary care can undergo transformative change, it can be done elsewhere.
There will be a way. Is there a will?
