Saturday, December 11, 2010

Triage, Part Two: Diagnosis

Nation, as outlined in my previous post "Triage", I'm trying to have an adult conversation with you all, as Albertans, about the root causes of the strains on our health system, which is either the worst in the country or the best, depending on the metric you use and (generally) the political party you support or oppose the most.

The comments in response to that original post have been extraordinary, and I want to thank you.  (See, Twitter? It IS possible for partisans to talk with each other like grown-ups!)

If we want to FIX the system, if we want to make it better, or to perfect it, we need to first identify what is truly wrong with it rather than dwelling on the sensationalist coverage of the symptoms - we know there are beds in hallways. We need to know WHY, and "Ed Stelmach is a bad man" is probably not the reason (nor, in my experience, even close to true. But that's just my opinion, and you don't have to share it.). We need to diagnose the malady before we come up with solutions. And I think we've gone a long way already towards doing that.

The original post stimulated some good debate in the comments section, and some great and well-thought-out and reasoned responses, even if I disagreed with some of them. Ultimately, though, this isn't about what *I* agree with, but rather what WE can come up with, as Albertans, to fix the system that we, our kids and our parents have to use. 

The discussion is timely, and it hasn't escaped my notice that the health care debate has shifted in some circles, due in large part to economic concerns, to a debate about "should we privatize ALL delivery, or just SOME delivery?".  While I'm open to having that conversation, I've got to respectfully submit that there is, in fact, a third option there: To privatize NO delivery (also known as, the status quo). I don't know if it's the correct answer, or the one most Albertans will support, but pretending this kind of delivery isn't an option because of the system's current condition is akin to Stephen Colbert's ironic "George W. Bush: Great president, or the GREATEST president?" interview question asked of presidential historians. 

Given the list of issues below: If ALL of them were addressed, and the system STILL didn't work with a full public delivery of services, THEN I'd say we were likely alright to discount it totally as an option. Once you've had the electrician over, checked the fuses and breakers and wiring, maybe it IS the light bulb that's the problem.  But given everything that's wrong with the system right now, we can't say that the appropriate response to a city-wide black-out is to change your house's lightbulbs to fluorescents.  Delivery is part of the debate. But it's not the whole debate.

According to you, these are some of the root causes of our systemic health-care issues: 
  1. Not enough experienced & trained medical professionals, incl. family doctors
  2. Misuse/overuse of the system for non-essential services
  3. Lack of care for the poor
  4. Limited access to non-trauma Urgent Care Centres
  5. Organizational instability/Governance issues
  6. Acute care beds being taken up by people well enough to leave but who have nowhere else to go (lack of long-term beds)
  7. Lack of personal responsibility for maintaining health/education regarding healthy & preventative living
  8. Over-medicalization of seniors
  9. Lack of home care support for seniors/disabled
  10. Lack of a team approach
  11. Front line staff bogged down by distant/out-of-touch/large bureaucracy
  12. Rising costs created by increased use of technology
  13. Lack of public education about which health care provider is appropriate in a given situation
What I'd like to do, in the comments section of this post, is to start to talk about solutions. If it gets to be too hard to keep the conversations straight, I may do individual posts for each problem - however, none of these problems exists in a vacuum (problems 2, 7, and 13 are related, for example).

In your comments, kindly identify by number the problem for which you're proposing a solution (e.g. "Re: Issue #1. Recruit doctors and nurses from across Canada by making ours the best paid in the country.") 

Don't be afraid to change the rules.  Big problems require big solutions.  I've got some of my own, such as increasing the role (and, subsequently, the education required & pay received) of Nurse Practitioners, to help deal with Issue #1.  I'll get into that in the "Comments" section, though.

This isn't going to be easy, but nothing worth doing ever is.

My favourite comment on the original post has to be this one, from Roberta:

"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."

Alright, Nation.
Let's fix it. 





k.w.m said...

Health classes from K -12 start with hand washing to sex ed , there are too many courses being closed down across Alberta, having health care as a mandatory subject to teach prevention and when to get needed medical assistance, can expand this yet again to in the prevention aspect as for after school completion, have health as part of Industrial arts in the prevention of injuries & accidents , too many young people out there are going into trades without any Idea of what they are facing as in daily dangers, some don't even learn over even at 20-30 years your still experiencing new things.

Enlightened Savage said...

k.w.m.: Thank-you for your solutions. I believe you're addressing Issue #7 - do I have that right?

John said...

I don't know exactly how to address it, but I believe problem #7 is the very root cause of all of the other problems. The vast majority of the others will be substantially addressed if we can achieve a change in social and cultural values as they relate to individual health and wellness.

Take me, for example. I work a sedentary job. While I once was more physically active, my commitment to it has always been tenuous, at best. I am a 41-year-old male who has been smoking for 25 years. And I am moderately overweight, but would not be described as obese. None of this is a result of lack of education; only lack of valuing health, clearly.

Addressing the problems in order and how they stem from this issue:

1 - If people were generally healthier, we likely would have enough, or at least a more manageable shortage, as people would make fewer visits.

2 - Because of poor health, generally.

3 - No data to back it up, but suspect "the poor" (whatever that means) are among those paying the least attention to their own health.

4 - Less users, greater access

5 - I don't even really know what that means.

6 - I don't think that people, generally speaking, are using hospitals as hotels. I don't think the health care system would tend to let them.

8 - Among the least healthy because many have spent a lifetime ignoring health. My almost-80 mother thinks that working in her yard is "exercise".

9 - Probably not related. If anything, this isn't lack of home care support, but lack of family support.

10 - Not related.

11 - Not related.

12 - Not related.

13 - Not related.

k.w.m said...

To me that would address 2,4,7 & 13

Addressing 1- immigrant Medical staff should not only take the last 2 years of Canadian health care training but also spend those 2 years in residency/assisting until they are proficient with our system and culture.

3- these is why we need to keep privatization out of our Health care , there are enough problems with the Labs/radiology etc, that are contracted out which slow things down due to corporate obligations.

5- fire 75% of the bureaucracy involved, many not around to give the "OK" or stop proceedings due to budget or some other reason that they fell they can control; we need front line workers including House Keeping more then we need paper shufflers.

6- That is not a proven situation and wrong to bring up, if that is the case then Social services should intervene.

8- back to #1 ,due importantly trained personal sent out on their own, We almost lost our 5 years old son due to that exact situation regarding a morphine overdose

9- as John said ; family needs to take more part in assisting , but that shouldn't allow for the Government agencies involved to deny their obligations, as that is already practiced with Disabled by Occupation.

10- all health professionals need to be a team , if they cannot do such then take away their Hospital privileges and replace with a team player.

11- read #5

12- being an experienced "Hospital Parent" I have seen many mechanical aids/ visual aids etc that I could make for less the 10% of what is billed (that included my sons body brace/ leg braces and a rotating visual projector for paralyzed children: as examples)

Art Hornbie said...

6. People, if given the option, will always choose the most appropriate "bed." It is a supply-of-bed failure within the monopoly medico system. The system is not responsive to health care consumer demand (but is instead responsive to the toys demanded by the suppliers of health care).

7. Personal responsibility. Why should any health care consumer be practically responsible for something over which they have absolutely no control. Give people free houses or free cars and they would simply burn through them one after the other. Everyone will demand the biggest and best right from the git-go.

My pay check is never enough, of course, but I manage to responsibly allocate it and prioritize it. Same thing would happen with a health-care-pay-check that I could spend or save for future contingency.

8. Over-medicalization of everybody! This is an efficiency issue. There is no restraint mechanism other than bottle-necking entry into the monopoly system. The suppliers of health care must excessively treat to cover-their-ass from pie-in-the-sky, unrestricted consumer demand.

Consumer demand can be restricted if appropriate, demand-driven health care is available.

9. Lack of home care.
This is simply inappropriate resource allocation. Perhaps our aging population would re-prioritize health care dollars toward this issue if they had the power. The suppliers of health care don't care to prioritize their dollars toward this end.

10. Team. Screw that. If I have consumer heath care dollars to spend then the health providing professionals will fall all over themselves with services trying to pry those dollars from my hand ... just like the malls at x-mas.

11. Front line staff are constrained by the mega-monopoly. No mega-monopoly works well. If we had one political party and one religion we wouldn't see any change there, either, and front-line staff would simply decry the system.

12. Technology costs.
Again, no mode of cost-benefit testing as there is only health care supplier control and no consumer of health care counter.

13. Make suppliers of health care flog their wares like everyone else. Truth is attained by competing opinion for a constrained dollar. We buy cars, clothes, toasters according to we miserly allocate our dollars in the face of infinite supplier encouragements.

Thar you go. Good luck with your solution-seeking exercise.

Art Hornbie said...

1. This is deliberate. Limiting medical professionals is a cost-control mechanism. Hence line-ups and inability to obtain valid option sets (second opinions).

They should not be limited. We do not limit realestate agents, food servers, auto mechanics, etc, and yet their numbers are in equilibrium.

Arguing that we cannot produce them in sufficient quantities is bogus, if you ask me. Virtually every professional occupation is "a degree and four+" years and yet they seem balanced enough.

A snap of the fingers and four months could easily produce thousands of qualified GPs and nurses from the immigrant sector alone. Add to that the potential of parallel health care (Alternative) professionals who have perfectly good health assessment training.

Supply is not an issue. System restrictions is the problem.

2. There is no misuse/overuse. People are not insane. Instead, people are deprived of access to sufficient, appropriate forms of assessment and treatment.

"The system" deliberately channels people to the rarest and most expensive resource ... the doctor.

3. (By "the poor," I assume you mean an "income class") It is a failing of public health care information and of access to health options.

The poor have no voice. I am sure, given the opportunity, the poor would avail themselves of the same benefits in health care as the rich.

The system is set up to meet as many of the "suppliers of health care" needs as possible. I think consumers of health care, if given the consumer-dollar vote, would cause an altering of medical prioritization.

4. Badly worded, this item. Non-trauma and Urgent [acute] are opposites.
We need specialized centres to treat trauma and very acute care cases.
From there we need a complete array of multi-disciplinary services as determined by the consumers of health care allocating their enabled, informed choice dollars.

5. Governance. Simply fund the consumers of health care rather than the suppliers of health care. Governance becomes a matter of licensing, inspection, facility, approval, etc.. The system will optimize itself as do all other facets of society.

Steve Clemens said...

Re issue #13: We already have a system in place that could be used to alleviate this, but maybe it isn't being used as effectively as it could be: Alberta Health Link. *Everybody* has a telephone. If you have a problem, the first step in the process is to call ABHL and they can direct you to the most appropriate health care provider (HCP). Maybe it has to do with cover-your-behind, but sometimes the most appropriate HCP is your bed. Send people away to a more appropriate place if they show up in emerg with a runny nose (or have a clinic right there to handle these cases).

Incidentally, perhaps it isn't just the public that is confused about the most appropriate HCP for a given situation. Maybe there wouldn't be as much of a shortage of doctors if some of the tasks that they do were done by others - kind of like how the dental hygienist takes care of most of the run-of-the-mill things so that the Dentist can take care of the things that require his/her skill.

I see this as giving nurses (and even pharmacists) authority to prescribe certain types of medications, and perhaps some diagnostic power. The latter would most probably require oversight by doctors, but one doctor could oversee several nurses and be more of an approval system.


I heard of a great idea on the radio a little while ago to alleviate wait times for surgical facilities (doesn't address surgeons): if I remember correctly it was the manager of the hospital in the Crowsnest Pass talking about transporting certain patients for certain surgeries to rural hospitals where there is space to perform the procedures.

Steve Clemens said...

PS I also think that people, in general, if given all of the options, will want to choose the most appropriate one.

Also, I am hesitant to believe that people are using hospital beds as hotel beds. Who, given the choice, wants to stay in a hospital any longer than necessary?

Enlightened Savage said...

Steve: Thanks for your thoughts.

Your example of the Dentist is one that I've used before, where your 40 minute check-up consumes 40 minutes of Dental Hygienist time, and 5 minutes of Dentist time. Your dentist can see 12 patients in an hour. The thought of adding a layer in between Doctor and patient bears investigation, and the example of a pharmacist or LPN is just what I was thinking (not that that fact makes it more credible - just nice to know I'm not alone).

Thanks to all for your comments thus far - perhaps you'd do me the favour of bringing this up over the holidays around the table, and post the solutions here for all of us to discuss?

With gratitude,