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A sick system 

Nova Scotia’s health care system won’t be fixed until patients, not bureaucracy, becomes the focus.

In August 2000, freelance writer Barry Boyce came down with a typical case of the Hospital Blues. In a column for the Halifax Daily News, he wrote that he "stepped in a hole in the floor of an old country barn," twisted his ankle, "and within minutes my foot was the size of a small watermelon." Over the next couple of days in hospital, he waited endlessly for fleeting visits from three different doctors and fasted a full day for surgery he ended up not needing. Although he felt he did get good medical care, he was never consulted about his treatment. "From the moment you start staring at the ceiling wearing only an open-backed shirt and peeing in a bottle," Boyce concluded, "no one will ever treat you like the independent, decisive human being you were in the days when you stood on your own two feet."

I remembered those words last week as I read John Ross's report on reforming emergency health care. Ross, who has more than 20 years experience in emergency medicine, was commissioned by the NDP government to recommend ways of fixing the many problems of hospital ERs including long wait times in city hospitals and the frequent closure of emergency departments in rural ones. His report paints a refreshingly frank picture, not just of emergency medicine, but of hospitals in general. "We want our system to be all things to all people all the time," he writes. "Mostly this unsustainable disease-care 'non-system' is anything but."

Ross goes on to point out that "health care" is managed and delivered by professionals who do not spend much time helping patients avoid disease in the first place. "Instead, the health-care professionals of tomorrow are trained in a type of reactive disease-care which strives endlessly for more expensive diagnostic tools and treatments." Ross adds that hospitals are increasingly organized for the convenience of health professionals rather than the needs of patients. "We have allowed the system to see the patient more as a burden than its very reason for being. To some, patients are 'cost drivers' and to others they border on being nuisances who get in the way of a smoothly functioning bureaucracy."

Ross's insistence that hospitals need to put patients first is at the heart of his many recommendations for fixing emergency rooms. He makes it clear that "people-centred" care means organizing things so that patients get treated quickly by teams of professionals who routinely share information among themselves and with the patient. He notes that "for too long we have taught nurses, doctors, social workers, pharmacists, physiotherapists and others in isolation from each other. That is not what a patient sees, however---a patient interacts with all disciplines." Best of all, Ross suggests that patients and their families be allowed to participate fully in medical decisions.

Ross recognizes that left on their own, powerful hospital groups such as professional administrators and medical specialists are highly likely to block or weaken such changes. In the case of emergency departments, he recommends giving the professionals financial incentives to meet new, patient-centred standards. Premier Darrell Dexter announced last week the government intends to follow Ross's advice by adjusting funding to reward better health results for patients. It's a hopeful sign, but the government will have to be exceptionally determined to make it work.

Unfortunately, the Ross report says little about a second crucial issue---the need to give local communities more power over health care. Volunteer community health boards can only provide advice to district health authorities and both are subject to strong centralized control from the department of health in Halifax. Ten years ago in an essay on the failure of the John Savage government's health reforms, political science professor James Bickerton argued convincingly that without real decentralization and democratization, it will be impossible to contain rising costs while making the health system more responsive to the people it serves.

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