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.
This article appears in Dec 16-22, 2010.
With a view to the first few sentences of your third paragraph, I’m not myself going to overly blame the health care community for being reactive when the majority of the people they take care of – us – don’t give a damn about being active about their health. The huge majority of the public is intelligent enough to know that adequate exercise, good nutrition, and moderation or abstention in consumption of alcohol and tobacco would make a big dent in ER visits and hospital stays and expensive treatments. However, the majority of the public can’t be arsed to do anything about it.
Dr Ross isn’t entirely wrong. The medical community, for generations now, has in fact been brought up with the idea that drugs and surgeries are the way to go. But without cooperation from the public these are typically also the only tools that the medical community has.
When we start talking about fixing ERs and empowering local communities and re-educating medical professionals we are so missing the point. The single, overarching root problem with health care is overweight/obese non-exercising people. Fix that and you’ve fixed pretty much everything else.
Realist, your grasp of reality is tenuous at best. And your grasp of what it will take to fix the problems of health care is the usual individualistically focused junk that you should know is just not true. Yes, many Canadians and Nova Scotians in particular, are overweight, don’t eat well and don’t exercise enough. However, do you really think it’s because we’re just too dumb to realise it? If it were so easy we could just make you minister of health and you could just magically make everyone eat well and exercise more. I say magically because of course, and you know this, it’s just not that simple. Are you going to ban junk food? Oh no, people have free choice and should choose healthier options because of course corporations have zero responsibility to their customers, only to maximise profits for their shareholders. Are you going to subsidise local farmers so that fresh fruits and vegetables are really cheap so that they become the easy choice? Oh no, that would be interfering with the free market. Anyway, you get the point.
Also, the evidence is overwhelming at this point that it is not individual choices that determine health. The most important determinants of health are income and equality within a society. The higher one’s income, the healthier one is. The more eqaul a society is, the healthier it is overall. After 20 years of neoliberal governance, is it any wonder that, as we’ve become a more and more unequal country, our health has worsened? No, it’s just reality.
Johnsmith: did I say that people are too dumb? If you actually read my reply, rather than seize on a few points that offend your socialist principles, you might have seen my exact words “The huge majority of the public is intelligent enough to know”.
“Usual individualistically focused JUNK”??? People exercising their free will to not smoke, drink not at all or in moderation, make a stab at eating right, and exercising, is “individualistically focused JUNK”??? Health *is* individual, and solutions start (and mostly successfully end) with the individual.
I know you’re on this class-inequality kick, and there’s no doubt that that’s a cause of many problems. Not health, however. The average person is much more wealthy now than the average person 50 or 100 or 200 years ago. Who cares that the richest 5% or 1% is unimaginably more wealthy? That’s irrelevant. Point is that the average person is more wealthy *NOW*. Your typical street bum is better off in 2010 than a labourer was in 1850. It obviously escaped your notice that the major diseases that afflict society now are what used to be considered rich people’s diseases.
I also notice that you completely ignored the near total adoption of sedentary lifestyles due to urbanization, radical changes in occupations, pervasive electronic entertainment, and the near universal Western adoption of the car as the preferred individual mode of transport. All of which have been made possible by rising *average* wealth.
Not only are your economics and politics bizarre and absurd, but you’re denying the ability of individuals to make appropriate choices. Instead I guess, in your world-view, that we need more of a Nanny State that can chase away those bad corporations, and take care of everyone, telling them exactly what to do to maintain health? Are you suggesting taxpayer-subsidized and government official designed “Healthy Meals”, and mandatory group exercise?
Here’s a clue. If, as you clearly agree, too many people are overweight, don’t eat well and don’t exercise enough, then there is in fact only one obvious solution. Exercise more, eat better and shed pounds. But somehow you managed to blame corporations and non-socialist governments instead. Astonishing.
Ah yes Nova Scotia, the Neo-Liberal province with 15% sales tax. Lets face it, our health-care system is under siege from many directions. Hospitals are over-populated, under-funded, under-staffed and the people there are under paid. Unfortunately, this is not a problem that can be fixed with more money.
Decisive action must be taken soon, but instead we’re talking about a $100 million convention center. I wish I had more faith in both our elected officials and our voters, but frankly I don’t. I’ll be eating healthy foods, exercising and praying I get lucky.
A two tier system is the only way to solve out problems, too bad it is so politically unpalatable to the ignorant masses out there.
The debate between Realist and johnsmith is, I believe, an important one. Overall, I side with johnsmith’s observations on overall determinants of health, yet there’s no denying that, as Realist points out, individuals should assume some responsibility for their own health — to the extent they’re able. For example, low-income families are obviously less able to buy nutritious foods than families with higher incomes.
The opposing views here can be summed up as a clash between “population health” (which focuses on social determinants of health) and “health promotion” (which focuses on individual choices).
Realist, you should know that in spite of your railing against the “Nanny State,” the population health approach is well-accepted by a wide variety of experts — although politicians of all stripes often seek to conceal this consensus.
In her 1999 book, “Health and Wealth: How Social and Economic Factors Affect Our Well Being,” Monica Townson writes:
“Federal, Provincial and Territorial Ministers of Health, who meet regularly to consider strategies to improve the health of the Canadian population, have also acknowledged that living and working conditions, early childhood development and physical environment are major influences on population health…Health officials have acknowledged the key things that need to be done, such a creating a thriving and sustainable economy with meaningful work for all; ensuring an adequate income for all Canadians; reducing the number of families living in poverty; ensuring an equitable distribution of income; and making sure there is suitable, adequate and affordable housing.”
In other words, population health is not only about individual choices, but also about political ones.
Anyone who is interested in exploring this topic further can read all about it on the Public Health Agency of Canada site at: http://www.phac-aspc.gc.ca/ph-sp/determina…
I believe people who willfully create their own health problems should PAY for their own healthcare. That’s the kind of 2 tiered system we should advocate for; accountability based. If you smoke, you PAY for your healthcare. If you are obese (not physiologically or genetcially based obsesity), you PAY for it. If you chose to get drunk and get lost in the woods, PAY for it. You would be amazed how all of a sudden people would start living better and stop being idiots. ACCOUNTABILITY is the best cost measure there is and it’s FREE. Free healthcare was not designed as another crutch for gluttony and stupidity, but to provide safe and equitable healthcare for people who become sick or injured due to no fault of their own.
I agree yyy – and it is the same nanny state through “health promotion” who have taken away all personal responsibility and have given it to the state instead.
Say all you want about how bad healthcare is in the USA – it does have its faults.
BUT. Survivability for a host of cancers and other terminal conditions is much higher there, and beyond that – your insurance rates are based on your behavior. It hits people in the wallet – where they really care – if they choose a lifestyle that precludes healthy living and for the most part a healthy life (e.g. smoking).
My grandfather is 95, lives in Florida (he’s American) and he waited _one week_ for a new knee – which his insurance covered no problem. Now he is back home feeling great after a week of physio. That kind of surgery wouldn’t even happen here – and if it did, he would most likely be dead before his number in the lineup was called.
Bruce: I’m not going to deny that there are elements of “population health” involved, and that this needs to be considered in a number of different ways. For example, I concede that for the poorest two income quintiles there are significant or at least noticeable spending qualifications on healthy nutritional choices. I also concede that public school physical education is now pathetic, although I lay the blame for that one on school boards; I doubt it’s a funding issue. I also concede that where the environment is unhealthy that’s clearly not a situation under individual control.
There are also situations where individuals can make the choices but the choices are currently inconvenient enough that a higher-level population-based solution is probably more realistic. An example of this is personal reliance on cars for transport, which has the side-effect of helping make us physically unfit. I don’t propose to beat this one to death here, but asking people to bike to work in Dartmouth Crossing from Hammonds Plains is a non-starter. So this is a problem that asks, in part, for a broad-based social solution.
However, johnsmith’s thesis that “the evidence is overwhelming at this point that it is not individual choices that determine health. The most important determinants of health are income and equality within a society” isn’t totally wrong, but he’s seriously missing the point. Income *is* important, but guess what? You don’t have to be in the top percentile, which is what I think johnsmith believes. You have absolutely no excuses if you’re in the top three quintiles, not many if you’re in the second-poorest, and you don’t have a complete pass if you’re in the lowest one either.
What I’m saying is that I find it difficult to comprehend a mindset that completely denies any personal responsibility when it comes to individual health. And based on what he wrote, that’s where johnsmith’s head is at.
A side personal note on my account:
I have many experiences with the health care in Nova Scotia that were not the most enjoyable. I have been treated in the hall-ways, sat up in a wooden chair while barely able to sit, as well as been completely forgotten about when the situation could have been important. I have had test results of CT scans, and blood tests, lost amongst the hospital setting.
One time, after being very ill and experiencing extreme sudden dizziness and vertigo with a sudden onset of my very first “classical migraine” I ended up in the out patients due to extreme agony and prolonged migraine and other such symptoms. I ended up getting an emergency CT scan of my head and the doctor in charge ensured me that the neurology department would contact me first thing in the morning and see me there as well. Alas, they did not. My mother and I were worried and contacted the neurology center and many other departments first thing that morning, and every person we spoke to were rude, and claimed that I had not even been in the emerge and that there was no such referral.
This went on for 24 hours. I never got the appointment, and no one ever helped me on it again. Recently, symptoms have became progressively worse and I went to my GP and she sent in another referral. It was reported that the reason I did not get another appointment right away is because I was a no-show to my last appointment (one that was scheduled for the morning after the emergency CT scan of my head). Thus, now I must wait another 2 months before I get into the neurology department for something that could have potentially been dangerous to my physical health.
This is just one of the MANY horrible experiences I’ve had with the healthcare system in Halifax, NS.