Saturday, November 27, 2010

Triage

Nation, it occurred to me quite suddenly earlier today that the best way to deal with the current situation in Alberta's public health system might be to deal with it in much the same way that a Doctor would deal with a patient who presented themselves at their office or ER.

  • First, you identify the symptoms and relieve them where possible.
  • Then, you follow those symptoms to their root cause. 
  • Then, you address the root cause, if possible.

Am I a doctor?  No.  But I DID stay at a Holiday Inn Express once...

Back to my point...  I think we're all aware of the symptoms that this particular patient is exhibiting: Over-crowded Emergency Departments, long waits to see specialists, staff working to - and, in some cases, past - the breaking point.  That's just to name a few.

The political response, and the response from the political media and bloggerati, has been predictable: Attack the government. This is all Ed Stelmach's fault, just like the global economic downturn was.  If we get rid of the PC's, all of these problems will be gone. Now, let's come up with a funny one-liner incorporating the word "cookie", and focus even more attention on a guy going through personal and professional hell in Dr. Sherman - hey, why not splash his marriage troubles all over the internet and talk some more about his father's impending death? I'm sure he'll LOVE that! (Note to the media: Sometimes, the moral thing to do is to shut off the mic and say "Thanks, I think we've got enough for the story.")  But first and foremost, let's solve every single problem in the system by getting rid of the PC's.

The problem with this simplistic approach is that it supposes that the health system is designed perfectly, and that the only problem with it is the people giving it political direction and setting the budget.  But I think if we're all being honest with each other, we can admit that Premier Smith would probably govern a RADICALLY different health care system than Premier Swann, Premier Mason or Premier Huff.  So, we've got to dig a little deeper for real solutions.

If we're all seeing the same symptoms, then what I want to know from you, the millions of members of E.S. Nation, is this: What do you see as the root causes of these symptoms? Is it board-level governance? A lack of financial resources? Low staff levels? Do we need more facilities, or a different sort of facility altogether?

There are likely as many answers to this question as there are people in this province, but if we're going to try and treat the disease rather than the symptom, we need to have an adult conversation about what the true root causes of these problems are - a conversation that's more nuanced and honest than "the PC's are the problem".

I've read with interest the health proposals from the Wildrose Alliance and from the Alberta Liberals. There are some good short-term and long-term suggestions.  I hope to read the proposals from others as well. But those are political parties, whose motivation can't be assumed to be pure any more than the governing party's can be by those in this province who oppose them. While I hope that all of these proposals are made from a place of genuine concern and a genuine desire to fix the system, I'm at LEAST as interested, probably MORESO, in what you - the public - have to say on these issues.

In summer of 2012, no matter WHOM is answering the phones in the Premier's Office, we're all going to be using this public health system. We've got to help fix it. But before we can do that, we've got to figure out what's truly WRONG, so we know what to fix.

So, I put it to you, Nation: What are the root causes of the distress on Alberta's public health system?

16 comments:

Enlightened Savage said...

Reginald Tiangha contributes, via Twitter:

"Bed shortage to a point, & then it becomes an issue of not enough experienced & trained professionals to serve patients"

Styles said...

My personal opinion of the root cause is misuse of health care. People go to the emergecy room with the slightest symptoms. This increases wait time, takes away beds and doctors, and generally slows the entire process down.

leslie said...

Not enough family doctors means too many people have to go the ER. Staff shortages mean bed closures and ER backlogs and wait times. Lack of care for the poor means they're more likely to get sick or injured.

Enlightened Savage said...

Pulled from Daveberta's post on the issue of last week at:

http://daveberta.ca/2010/11/public-health-care-is-not-broken-it-just-needs-some-tender-loving-care/

(I'm paraphrasing here, so feel free to correct me, Dave):

- Serious under-staffing
- Difficult to find a family doctor
- Limited access to urgent care centres, leaving ER as the only option for many
- Organizational instability

From Dave's commenter Ardvark:
"IMHO: The root of it all is that too many acute care beds are being taken up by people well enough to leave but have no where else to go."

Commenter James:
"I recently spoke to some current and retired ER doctors and they indicated that a significant part of the problem with wait times in ERs is the issue of people using ER for inappropriate reasons. Going to Emerg everytime you have the sniffles or a sore knee is not a good use of resources. A significant number of people go to ER because they don’t want to wait in line at the clinic or make a doctor’s appt. People need to stop wasting resources and look after their own health. And they need to reserve the health care system for times when they really need it."

Duncan throws in a solution while identifying a problem:
"If we’re looking at “fixes” for wait times and the other “ills” of our system, lets look at the # of doctors we have. Most of Western Europe has over 30 docs/10,000 population. We have 19. Even the US beats us (21). If we want to improve the system, we need to train (and recruit) more doctors."

Commenter Roberta, with some great points:
"It’s not a simple matter of ER fixes. Systemic issues include the over-medicalization of seniors; lack of home care support for seniors/disabled; unavailability of family doctors; lack of a team approach; lack of support for prevention. Even making sure people have knowledge about nutrition and the ability to cook would improve health outcomes!

The whole system needs a relook from the bottom up – but it has nothing to do with who pays. We need to completely examine what we’re doing and why."

Enlightened Savage said...

More from Twitter - great! Keep 'em coming!

Reginald Tiangha writes:
"Also I think that front line staff should be empowered/given power to make whatever decisions they feel to deal w/ crisis"

Shafiq Shajani opines that management is too far from the front lines.

TrinaMB wonders "are we being truly effective w/ our existing resources? People/places. I hear of top heavy admin".

Hank said...

I think there's many people who are going to say hire more doctors.
One group who might not say this: Doctors.
The more doctors, the less doctors are in such demand, the less they get paid. There is a reason the College of Physicians haven't been pushing for a great influx of the foreign trained docs to be allowed to practice in AB.

If someone can prove me wrong with some quotes from the College, please do.

Anonymous said...

Not enough long-term care beds. Quit adding acute care beds, which are more expensive and then get filled up with folks who should be in long-term care facilities. meanwhile people in need of acute care wait for a bed. Long-term care beds are cheaper too.

Alexander Muir said...

The shortage of doctors is one of the fundamental causes. Another is our emphasis on treatment instead of prevention and public health. We need to move on rectifying both of these as elements of any long-term plan going forward.

Kate said...

A large part of the problem is that most people don't take responsibility for the health and safety of themselves and others. A very large portion of ER visits are preventable. johnnyfever comments on my blog post and points out that there are significant problems in the administration. Check it out at http://crude-politics.blogspot.com/2010/11/stay-out-of-my-er.html
Act safely! Live healthy! Help health care work for Albertans.

Brent said...

Lack of capacity is a key issue, as already mentioned. It manifests itself throughout the system...ER's, ward rooms, lack of family docs, and lack of supports for seniors and long term care beds.

We spend $4 billion to build the trophy-South Campus hospital, and then don't add any operational capacity to staff it. In fact, we have lost capacity, because we closed the smaller regional health centres and hospitals in anticipation of the South Campus being able to serve areas to the south.

Rising costs created by increased use of technology and innovation also plays a significant role. Finding new ways to extend lives is very expensive.

I think we may need to back up even further on this, and ask to define: "what is health-care?" I can't see without glasses, but that's not health-care. Conversely, my neighbour can't see with a cataract, and that is health-care. Unfortunately, our health-care system has just become a list of services from which we pick that which the province can afford, and leave off that which it can't. It's an arbitrary process and not based on any real vision (excuse the pun) for what we really want to get out of the system.

Many are sold on the idea that health-care is "anything you want, till death do us part". The correct phrasing (in my humble opinion) is "anything you NEED, till death do us part," and it's not an insignificant difference. Once our vision of health service delivery is more clearly defined, then we can spend some money on properly resourcing it. Otherwise, it feels like we're just throwing money into a pit.

Enlightened Savage said...

Brent: Thanks for your insightful (no pun intended) comments.

I have to wonder if there are jurisdictions that have run "free health care isn't free" education campaigns, where they try to educate the public about the costs, monetary and otherwise, of unneccesary use of the system. If so, I'd be interested to know the results.


Case in point: I have coverage, through work, for chiropractic care. I know for a fact that my coverage limit is $500, and each session costs $40. Knowing that I have limited coverage, I make a conscious choice when experiencing back pain as to whether I really NEED to go and get it looked at, or whether it's a minor back spasm brought on by being as ancient as I am. If I was under the impression that chiropractic care was "free", the way many people think of visits to the family doctor or the ER, I'd probably go every time I woke up with a stiff neck, overloading the chiropractor's office and resulting in a 3-week wait to get in, as opposed to the same-day service I can expect currently.

So, to whit: I'd suggest one Root Cause is the mis-use or over-use of the system, as mentioned by Brent, Kate, and James. Didn't mean to get into a "solution" there - that's going to be our NEXT conversation, once we get done with Root Causes. :)

Thank-you ALL for the input so far - let's keep at it, and build a better Alberta for ALL of us!

Brent said...

Is there "unnecessary use" of the system though, or is that just a perception? While many ER visits are not worthy of a television ER episode, they may not be unnecessary, but rather they're probably better dealt with via family doc or clinic.

Directing people to the correct health care provider is the critical aspect, as an ER costs $500 per visit, and a family doc costs $35.00. To do that though, we need to have access to the family doc or clinic, which is a missing ingredient right now. Whether or not a visit is legitimate should only be a discussion between the health-care provider and the patient.

The Canada Health Act doesn't allow us to restrict access to treatment, but we've lost our gatekeeper (to both treatment, and cost management) with the gradual demise of the family doc.

Showing someone a bill (or making them participate in the re-payment), is really just a marketing campaign and moot for those that are requiring in-patient treatment. No one has the option of "choosing" to be in the ICU. Patients are there because they're sick and that's where the doctors put them. That said, this is where the real costs add up. $750-$1500 per day, which add up quickly on a billing statement, and patients are not capable of making a decision on whether to be there based on cost to the health-care system. Instead of showing those costs to patients, we should be showing them to administrators and politicians, who might feel inclined to add more capacity to wards, or increase the number of family doctors. If a patient is well enough to transfer to a ward or long-term care bed from an ICU bed, but can't because of lack of capacity, the difference in cost is equal to 20+ family doc visits.

I recognize that no one is making a choice between a family doc visit vs a stay in the ICU. But if I'm looking at ways to increase capacity, I'm focusing my efforts on finding ways to increase accessibility to our most affordable health care providers. My 2 cents - Brent.

Eric said...

The root cause, at the fear of sounding overly philosophical, is the problem of matching unlimited wants/needs with limited resources. How to get supply to equal demand.

There are 3 basic ways of doing this, the family way, the queue, and the free market:

1) Family way: everyone is the family works and shares what they make with resources being allocated by agreement. Easy in small unit like a family it is easy to see who is "faking" (saying they need something they don't), or freeloading (not bring in their fair share of resources). It’s very tough to see and enforce this one a large scale.

Thus why socialism falls.

2) Queuing: Everyone waits their turn. When you go into a bank you don’t have a meeting with all the other people waiting to decide who is more disserving, you just wait your turn.
3) Free market. You pay for what you get. You want a great food you pay more, crappy food pay less. The cost of the item makes our demand equal the supply. If demand goes up, the price goes up. A higher price reduces demand. The same is true with supply. The higher the price the higher the supply, and vis-a-visa. Thus supply will equal demand.
What system do we have? Is mainly the queue system with a little of the family system and the free market.
Imagine if the government ran grocery stores and the food was free. Everyone would want the best food; we would go to a dietitian and explain our food needs. They would write us up a prescription for food. We would then wait in lines, like the old Soviet Union, for different food items. In may take weeks, months or years to get what we want. But some people, clearly starving could get emergency food, but of course lots of people would go to the emergency food store because they know there is at least a chance they will get food sooner then if they wait in the regular line. Lastly there would be a few rich people who would drive down to the US or somewhere else and buy food. And by the way those who run the grocery stores would make sure they and their families are taken care of.
We need to stop looking for the SOLUTION. There is no solution to the problem of unlimited wants/needs verses limited resources. There is a better solution but no perfect one. Our current system of queuing has failed in every industry, only the government can lose money running an oil company, and every country it has been tried (Cuba to the Soviet Union to Nazi Germany), what makes us think it can work here. One and half million bright hard working people could plan the soviet economy, 10,000 bright, hard working people can’t plan health care in Alberta. It is unfair and irrational to think they can. No one can.

Perhaps the answer is found in our imperfect welfare system. We do not supply free food to everyone but will give money and food so no one should go hungry. The government doesn’t own the grocery stores and doesn’t need to; it just supplies money to the less well off. It is not a perfect system. Both the left and right can agree on that but one must never make perfection the enemy of improvement.
In health care we should privatize all health providers. Emergency care should be free to the public and paid by the government and charities. The moral equal of food banks, drop in centre, etc. Other care is covered again by the government and charities. Again the equivalent of welfare, job training, habit for humanity, etc.
This will not be a perfect solution, but we must get past the idea that there is a perfect solution and that if only we spent a little more money or had the right person running things or reorganized this board or that, everything would be perfect. The definition of insanity is to keep doing the same thing and expecting a different result. As long as we have government owned and operating socialized medicine, we will get the same result as we are currently receiving.

Eric said...

The root cause, at the fear of sounding overly philosophical, is the problem of matching unlimited wants/needs with limited resources. How to get supply to equal demand.

There are 3 basic ways of doing this, the family way, the queue, and the free market:

1) Family way: everyone is the family works and shares what they make with resources being allocated by conscencience, with certain people - those in general bring in the most resources having the greatest say - the parents.

In a small unit like a family it is easy to see who is "faking" (saying they need something they don't), or freeloading (not bring in their fair share of resources). It’s very tough to see and enforce this one a large scale. Thus why socialism falls.
2) Queuing: Everyone waits their turn. When you go into a bank you don’t have a meeting with all the other people waiting to decide who is more disserving, you just wait your turn.
3) Free market. You pay for what you get. You want a great food served to you at home by a professional chief, you pay more. You want a crappy food and willing to cook your self, you pay less. The cost of the item makes our demand equal the supply. If demand goes up, the price goes up. A higher price reduces demand. The same is true with supply. The higher the price the higher the supply, and vis-a-visa. Thus supply will equal demand.
What system do we have? Is mainly the queue system with a little of the family system and the free market.
Imagine if the government ran grocery stores and the food was free. Everyone would want the best food; we would go to a dietitian and explain our food needs. They would write us up a prescription for food. We would then wait in lines, like the old Soviet Union, for different food items. In may take weeks, months or years to get what we want. But some people, clearly starving could get emergency food, but of course lots of people would go to the emergency food store because they know there is at least a chance they will get food sooner then if they wait in the regular line. Lastly there would be a few rich people who would drive down to the US or somewhere else and buy food. And by the way those who run the grocery stores would make sure they and their families are taken care of.
We need to stop looking for the SOLUTION. There is no solution to the problem of unlimited wants/needs verses limited resources. There is a better solution but no perfect one. Our current system of queuing has failed in every industry, only the government can lose money running an oil company, and every country it has been tried (Cuba to the Soviet Union to Nazi Germany), what makes us think it can work here. One and half million bright hard working people could plan the soviet economy, 10,000 bright, hard working people can’t plan health care in Alberta. It is unfair and irrational to think they can. No one can.

Perhaps the answer is found in our imperfect welfare system. We do not supply free food to everyone but will give money and food so no one should go hungry. The government doesn’t own the grocery stores and doesn’t need to; it just supplies money to the less well off. It is not a perfect system. Both the left and right can agree on that but one must never make perfection the enemy of improvement.
In health care we should privatize all health providers. Emergency care should be free to the public and paid by the government and charities. The moral equal of food banks, drop in centre, etc. Other care is covered again by the government and charities. Again the equivalent of welfare, job training, habit for humanity, etc.
This will not be a perfect solution, but we must get past the idea that there is a perfect solution and that if only we spent a little more money or had the right person running things or reorganized this board or that, everything would be perfect. The definition of insanity is to keep doing the same thing and expecting a different result. As long as we have government owned and operating socialized medicine, we will get the same result.

Anonymous said...

It's time for Raj Sherman to resign. Now.

Anonymous said...

The root cause of healthcare malaise is socialism.

Secondary symptom, bureaucracy.

Tertiary, a learned helplessness on the part of the public regarding solutions.