About That Healthcare Redevelopment Plan…

Okay, don’t kill me, but I’m not sure this healthcare plan for Cape Breton is all bad. [Ducks under desk. Waits for boos to subside.]

I may be a little jaded about the loss of physical buildings, given that the hospital I was born in, the elementary school I attended and the junior high school where I passed my awkward adolescence have all been demolished and the high school I graduated from is no longer a high school. (I really have no idea where I’m going to affix this plaque recounting my life story I had made up a couple of years ago, knowing it highly unlikely anyone else would ever commission one. For now, I’m wearing it around my neck.)

Attendees to listen to announcement about CBRM healthcare "redevelopment." Joan Harriss Cruise Pavilion. 25 June 2018 (Photo by Charlie Morrison)

Attendees to listen to announcement about CBRM healthcare “redevelopment.” Joan Harriss Cruise Pavilion. 25 June 2018 (Photo by Charlie Morrison)

But of course, it’s not so much the loss of physical buildings that matters as the loss of services, which is why I’ve been straining my brain trying to determine what the changes will actually mean in that regard.

I’ve also been marveling at just how incredibly ham-fisted the government’s handling of the announcement was. Sometimes how you do things can be almost as important as what you do — a notion that was driven home for me on Monday as I watched the livestream of Nova Scotia Health Authority (NSHA) CEO Janet Knox and Premier Stephen McNeil presenting the plan to an audience I can only describe as “largely hostile.”

Equally hostile has been much of the reaction I’ve seen on Facebook.

In fact, such is the level of hostility in the air, I find myself feeling uncharacteristically sorry for the government, even though it has brought the opprobrium upon itself by being so damn high-handed about everything — I’ve seen a CBRM councilor complaining that the press conference was held on short notice, with no information provided beforehand and no questions answered after, and a doctor complaining she first heard of the plan to close the hospital at which she works on the radio.

Monday’s Cape Breton Post contained accounts of doctors — like Margaret Fraser — and local politicians — like MLA Eddie Orrell — being notified at 5:00PM on Sunday night that a big healthcare announcement was coming the next day at 11:45AM.

More damningly, local medical professionals are complaining they weren’t consulted about the plan itself. (Premier McNeil’s response to this criticism was to tell CBC’s Information Morning Cape Breton on Tuesday that now they’re going to consult.) And given this is the same government that merged nine provincial health care authorities into one mega-authority to less-than-rave reviews (ranging from “not agile enough to respond to local needs” to “prone to political interference”), it’s not surprising people are wary of anything it proposes in terms of healthcare reform.

In fact, when I asked Chris Parsons of the Nova Scotia Health Coalition, a healthcare watchdog group, what he made of Monday’s announcement, rather than address any particular aspect of the plan, he focused on the way it was announced:

I do not think that this government has thought through the impact that this style of announcement will have: with no warning they just shuttered two hospitals after denying for months that there was any plan to shut them down. How are communities in places like Digby or Shelburne supposed to recruit doctors now with the possibility of an out of the blue announcement of hospital closures hanging over their communities? How are they supposed to encourage people to move there to start families or businesses that their communities need to be viable?

This seems like really dumb politics to me — springing this plan on unsuspecting, un-consulted people is pretty much guaranteed to piss them off to the point where the plan itself can get lost in the kerfuffle.

But the plan presented Monday really should be assessed in terms of what it contains (or doesn’t contain) not who presented it or how.

So let’s try and ignore the messengers in this case and concentrate on the message.

 

The Plan

As you know by now, unless you’ve been binge-watching hospital dramas on Netflix instead of watching this one play out in real life, the provincial government plans to close the New Waterford Consolidated Hospital and the Northside General Hospital and replace them with Community Health Centre & Long-Term Care Facilities in New Waterford and North Sydney.

The centers will provide many of the services currently available in the hospitals — day clinics, blood collection, x-rays and, on the Northside, dialysis and endoscopy — as well as “community-based health services” like mental health and addictions and diabetes education. The centers will also house “collaborative, primary-care healthcare teams made up of doctors, nurses and other health professionals.”

CBRM Health Redevelopment (Source: YouTube)

Illustration of Community Health Clinic collaborative team from CBRM Health Redevelopment video. (Source: YouTube)

Each facility will also include an “estimated” 48 new long-term care beds for a net gain of 50 such beds and the Northside facility will include a laundry centre serving all CBRM healthcare facilities.

What the new health centers will not provide is emergency services — those will be handled by the Cape Breton Regional Hospital and the Glace Bay Hospital out of expanded Emergency Departments (EDs). (But I think it’s worth noting that, given the number of closures experienced annually due to staff shortages at the New Waterford and Northside EDs, they haven’t really been providing such services, certainly not in a reliable way, for some time now.)

The Cancer Centre at the Cape Breton Regional Hospital will also be expanded — by 20,000 square feet (basically doubling its size).

A community-based paramedic program will provide in-home patient care and follow-up visits after hospital care. This service “could” be up and running within six months and is expected to cost $900,000 annually. Speaking to the CBC’s Information Morning Cape Breton (which has been providing great information about the proposed healthcare changes) on Wednesday, Jeff Fraser, director of provincial operations for Emergency Health Services (EHS), said the initial program “envisioned” for Cape Breton is for follow-up visits after a patient is discharged from hospital.

 

Deets, please

The government has provided neither timelines nor cost estimates for most of these proposed changes, leaving people like me to fret it will opt for private-public-partnerships (P3) to undertake the new construction. This is a problem, because P3s are notorious money pits — great for developers, less so for the citizens footing the bills. (It’s a lesson we should have learned after the great P3 school fiasco, but did we?)

The next step in the process, according to the government, is the functional planning phase, which is expected to take 12 months and cost $500,000. Timelines — both for new construction and changes in services — are expected to emerge from this process as are details about many aspects of the plan.

Here are some of the areas where more detail is sorely needed:

Staffing

The government said the changes will involve no staff cuts, but remained silent on the question of staff increases. For example, it describes the expansion of the Cancer Centre purely in terms of physical space — an additional 20,000 square feet. As for the Emergency Departments (EDs) at the Regional and Glace Bay Hospitals, the factsheets say they will be “redeveloped” increasing “space” by an estimated 40% and 30%, respectively.

Speaking to CBC’s Information Morning Cape Breton on Tuesday, Chris Milburn, emergency doctor and emergency services chief for the Nova Scotia Health Authority’s eastern zone, said the expansion of the EDs (which he spoke of in terms of bed capacity) would require additional physicians and nurses.

But Brett MacDougall, executive director of operations for the NSHA’s eastern zone, told me in an email that the estimates for the ED expansions are related to “physical space.”

The exact space and resource requirements, including additional staffing, will be part of the planning.

In terms of patient capacity, Glace Bay for example does not currently have a suitable space for assessing patients (triage) when they arrive at the emergency department, or to register patients in private. The layout doesn’t work well for the way care is provided today. The space needs to be reconfigured for better patient privacy, comfort and movement.

The situation at the Cape Breton Regional Hospital emergency department was not designed to care for the number of people it sees today and needs to be modernized.

So, if I understand correctly, the 40% and 30% increases in physical space do not necessarily mean 40% and 30% increases in bed capacity. We won’t know what the increase in bed capacity (or staff) will be until the functional planning phase is completed.

Cancer Centre

The Cape Breton Cancer Centre expansion will more than double its size and not a moment too soon, apparently — according to MacDougall, the facility was built to handle 16,000 patient visits a year and in 2017 it handled 30,485. (MacDougall underlined that these figures refer to patient visits, not patients.)

According to the government factsheet, the new space (an additional 20,000 square feet, as noted above) will “help meet the needs of clients and support clinical trials and research,” but the factsheet is silent in terms of what this will look like, in practical terms (a larger reception/registration area? Bigger waiting rooms? More chemo chairs?) and whether it will entail additional staff. I asked MacDougall who told me:

The Cape Breton Cancer Centre (CBCC) provides multi-disciplinary care to cancer patients across the Eastern Zone. The programs include systemic therapy, hematology oncology, radiation therapy, gynecological oncology, preventive oncology, palliative medicine and supportive care.

The existing space is insufficient to support the current workload volumes and will not support the projected growth in demand for treatment services…

An [i]ncrease in space will allow for increased clinic space; create improved space for patients accessing supportive care services; and support clinical trials, research and education.  The exact space and staffing requirements will be determined th[r]ough the planning.

Surgeries

Surgical services is one area with a big question mark over it — the plan is to move surgeries now done in New Waterford and the Northside to the Cape Breton Regional and Glace Bay Hospitals but it doesn’t include any expansion of operating room space. The factsheets estimate the move will mean an additional 1,700 surgeries at the Regional Hospital and 1,600 at the Glace Bay Hospital — that’s a significant additional burden.

Dr. Abdul Atiyah, a plastic surgeon who works out of the New Waterford Consolidated Hospital, told the Cape Breton Post Monday’s announcement caught him completely off guard. In addition to plastic surgeries, the New Waterford hospital also handles pediatric dental surgeries and Atiyah worried the Cape Breton Regional Hospital “in its current structure” would not be able to handle these functions. He said he had no idea where he, personally, would be located once the New Waterford hospital closed.

Clearly, there are a lot of details to be filled in here and (full disclosure) I did not ask MacDougall about surgeries — but I will.

 

Beds

The number of beds will increase at the Glace Bay and Regional Hospitals but the “number and mix” is to be determined by the functional plan.

Enhancements

The terrible word “enhanced” is used in the factsheet to describe what will happen to day clinics and community-based services (like mental health and addictions and diabetes education). As is the case pretty much anytime the term “enhanced” is used in a government publication, more detail will be necessary.

CBRM Community-Based Paramedic Program

The expanded use of paramedics is expected to improve the situation in local Emergency Departments, as paramedics will perform in-home assessments to determine if patients actually need to go to the hospital. According to NS government spokesperson Tracy Baron, since the launch of a community-based paramedic program in Halifax, 77% of calls to nursing homes have not resulted in trips to Emergency.

This seems like a good place to raise a concern I’ve seen expressed on social media by people who fear traveling the extra distance to get to the ED in Sydney or Glace Bay in case of an emergency would be dangerous — first, in that it would be a longer trip for someone who had, say, suffered a heart attack. But Chris Milburn addressed that issue during the above-mentioned CBC interview, saying that a person having a heart attack — even if they had the heart attack in the parking lot of the Glace Bay Hospital — would be taken to the Cape Breton Regional for treatment because it is best equipped to handle such emergencies. Moreover, he pointed out that paramedics are able to administer meds like clot-busters while en route to hospital.

Still, that doesn’t address the issue of people driving patients to hospital themselves because the option of calling an ambulance is too expensive. (A reality already faced by people living in say, Louisbourg or Eskasoni.)

Dr. John Ross raised the issue of ambulance costs in his 2010 report on emergency services in Nova Scotia, “The Patient Journey Through Emergency Care in Nova Scotia:”

The ambulance fees charged by Emergency Health Services (EHS) are not well understood by the public, and may be a barrier to using the service. Worrying about having to make a choice between calling an ambulance or buying food for the family should not be a concern during a medical emergency.

I went through the entire report, looking for the part where the EHS ambulance fees were explained, but all I found was:

This highlights the need to revisit the whole fee structure for ambulance transport—especially for emergency calls.

Luckily, they’re spelled out on the Department of Health and Wellness website:

Source: NS Department of Health and Wellness https://novascotia.ca/dhw/ehs/ambulance-fees.asp

Source: NS Department of Health and Wellness https://novascotia.ca/dhw/ehs/ambulance-fees.asp

 

The province does “recognize that not everyone can afford ambulance fees.”

If an ambulance fee will create financial hardship, we will offer you a repayment schedule. If you aren’t able to pay your bill because you don’t have enough income, you can apply to have the fee waived. You must do this within 90 days of the date on the bill. Please note that we base that decision on Statistics Canada’s Low Income Measure.

That’s something, but if an ambulance fee is a financial hardship, it will be a financial hardship on a repayment schedule, albeit a less acute one.

(For the record, Jeff Fraser told the CBC that in the case of home visits under the Community-Based Paramedic Program there is no fee.)

 

Emergency Services

As I mentioned, I’ve been reading Dr. John Ross’s report on emergency care in Nova Scotia and I think you can trace many elements in the Liberal’s healthcare plan to it — although they seem to have skipped over Recommendation 19:

Communicate, communicate, Communicate. History should have taught us that consultation, discussion, and collaboration are necessities for a successful outcome during periods of difficult, but necessary, change.

The Ross report points to two main problems with emergency services in Nova Scotia and both originate outside the actual ED.

The first is that many people go to the emergency department not because they have an actual emergency of the life-threatening kind but because they have a medical problem and either don’t have a family doctor or can’t get same-day or next-day or after-work access to their family doctor. (Waits of seven weeks were not unheard of in some Nova Scotia towns at the time Ross was writing.)

Ross’s first recommendation for improving Emergency Services was to improve access to primary care which, as he explained elsewhere in the report, doesn’t necessarily mean access to a doctor but could mean access to a nurse practitioner or a Family Practice nurse. He also suggested “strategically placed walk-in or after-hours” clinics as another primary care delivery model.

I don’t think the plan announced Monday does much to address this problem, although the Community Health Centres will offer access to a variety of health professionals and, who knows, might even offer evening hours. But the thorny problem of primary-care access clearly will have to be addressed if this healthcare “redevelopment” plan is to succeed.

The second problem in our Emergency Departments is that there’s a shortage of long-term care beds in the province. This means that patients who should be entering nursing homes are occupying hospital beds that would otherwise be given to the small percentage of the people who go to Emergency and actually need to be admitted to hospital (according to Ross’s 2008-09 data, 2% to 4% of all patients seen in rural EDs are admitted or transferred to another hospital; in a regional hospital, like Sydney, those numbers are 6% to 8%). These patients then occupy the beds in Emergency that would otherwise be given to the new patients who are arriving but cannot be admitted. And the paramedics who’ve brought the new patients in are also stuck, because they cannot leave until their patients have been checked in.

Here in Cape Breton County, the median wait time for a nursing home placement, as reported on the Department of Health and Wellness website, is 350 days. The longest wait — 577 days — is for Harbourstone while the shortest — 266 days — is for Seaview Manor. The shortest median wait time in the province — 36 days — is in Cumberland County.

The Liberal’s healthcare plan does at least attempt to address this problem, with the addition of a net 50 new long-term care beds, although that does have the faint, ringing sound of a drop in the bucket.

But the bottom line with EDs is that they are supposed to be for emergencies. As Milburn told the CBC, if EDs are overrun by people who are either in need of primary or long-term care, the answer is not to expand the ED, it’s to expand access to primary and long-term care. It’s the difference between solving your leaky roof problem by getting a bigger bucket to catch the drips or fixing the leaky roof.

Premier Stephen McNeil announces planned changes to CBRM healthcare system. Joan Harriss Cruise Pavilion, Sydney, 25 June 2018. (Photo by Charlie Morrison)

Premier Stephen McNeil announces planned changes to CBRM healthcare system. Joan Harriss Cruise Pavilion, Sydney, 25 June 2018. (Photo by Charlie Morrison)

 

 

Good medicine?

I think that while its preparation and presentation have left a lot to be desired, this plan shouldn’t simply be dismissed out of hand. The bottom line for me is that healthcare isn’t just about hospitals. In fact, hospitals in some ways represent the failure of healthcare: you end up there because you are sick.

Obviously, some illnesses cannot be prevented. But many can — through diet and exercise and stress-management. And some more serious illnesses can be avoided by helping patients with chronic conditions like diabetes keep them under control. And don’t even get me started on the links between poverty and poor housing and illness. But this holistic approach to healthcare is what the collaborative care model of medicine is supposed to be about — don’t just consult a doctor, consult a doctor and a nutritionist and a social worker and a mental health specialist. (That’s the way it’s done at the North End Community Health Centre in Halifax.) And we’ve been talking about shifting to a collaborative care model of medicine here for at least eight years (i.e. since I returned to Cape Breton, which is my self-centered way of measuring time).

But affected communities and medical professionals should have a say in the form the new system takes — right down to how the buildings themselves should look. There are lots of interesting things happening in hospital and clinic and long-term care facility design these days. Design ideas have evolved since 1954 when the Northside General was built and 1963 when the New Waterford Consolidated was built. What if the new Community Health Centres were green buildings?  What if they made optimal use of natural daylight? Conserved energy and water? Had gardens — flower or vegetable or both? There are so many possibilities.

Overall, I think the best summation of the plan was Dr. Chris Milburn’s. He told the CBC it had real potential to improve local healthcare — but everything will depend upon the execution. He used a good example, too — he pointed to the government’s seemingly well-intentioned plan, many years ago, to move handicapped people out of large institutions and return them to the community. Unfortunately, he said, the institutions were closed before the community housing was ready, which caused many problems.

“We need to make sure the government’s feet get held to the fire over the next few years” to ensure things go well.

 

 

 

 

 

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