Challenges for healthcare in the County

An Open Letter to the Community
This article is provoked by the announcement that two talented young physicians from the County are moving to Kingston.

Several years ago, I was involved in establishing the Prince Edward Health Alliance (PEHA), a collaborative partnership of key representatives of the Prince Edward Family Health Team, QHC, the Municipality, and local community health service agencies. The intention of the Alliance was to streamline access to County healthcare services. Co-locating and coordinating services, not only provides better and more timely patient care, but to reduce the enormous overburden of service duplication, red tape, and empire building that contributes so much to the ongoing financial crisis afflicting our health care system.

Since my retirement from active involvement in health care, I have watched events unfold:
•    QHC has used the PEHA as window dressing to punt the common campus approach into the never-never. By opting for the pipe dream of a brand “new” hospital they have put off any need for action or commitment by at least a decade – by which time the hospital will be closed and the problems will be entirely different. Opinions to the contrary are either misleading or naïf.
•    The South East LHIN has always been a solution in seek of a problem, but it is increasingly exhibiting many of the characteristics of bureaucratic, passive aggressive, control freaks.
•    In issuing yet another set of short term draconian across-the-board budget cuts, the Ministry of Health (hiding behind the LHIN) has succumbed to a complete loss of courage by refusing to address the regulatory anachronisms, organizational rigidities, entrenched interests  and wage settlements that are the real drivers of health system costs.

But, for me, the final straw has been the loss of Drs. Forster and Lett. I know that their decision was motivated by family as well as by system concerns. I deeply respect their decision and I wish them well, but their leaving is the unmistakable human evidence of the monumental stupidity of those in charge of rural health care policy and systems for rural Ontario.

This is not a time for despair. I once had an engineer colleague who used to say that some problems cannot be solved: they can only be “re-solved”. You have to redefine the problem you are facing in order to make any solution possible. In this light I want to offer some thoughts and (hopefully) encouragement based on my past involvement with health care in Prince Edward County.
1.    Hospital Beds are a symptom not the real problem
The technologies and best practices of health care are constantly evolving, but Acute (hospital) care is based on the entrenched definitions in the Hospitals Act vigorously defended by large bureaucratic institutions. Not only is this rigid system extremely costly, it is inefficient and often contributes to patient decline not recovery. For this reason, keeping patients out of hospital beds or minimizing stays is important, but it is utterly irresponsible to slash hospital beds without conclusive evidence of net overall savings and without first offering a better alternative.

The only viable solution is to move to providing key hospital services on a more flexible integrated basis with other healthcare services, including home care, hospital-at-home. and care provided in other local sites (e.g. Hospice). Such integration takes time to implement, but even that is not possible as long as hospital services are delivered on a rigid institutionalized model with a monopoly over access to crucial diagnostic and support services. The problem is that with their large budgets, the hospitals dominate the system and feed their own narrow, institutionally-defined interests.
2.    QHC cannot evade its responsibility
On the issue of budget cuts, QHC has pointed fingers at the Province and the LHIN arguing that its hands were tied by decisions from above. This is nonsense. The whole point of hospital boards is to provide for a measure of local decision making. The PEHA experience makes it clear that QHC has opted to hide behind the rule book by running a tightly controlled hypothetical planning exercise instead of engaging in proactive collaborative problem solving to prepare in advance for the next inevitable budget crunch. The result is that QHC is again revealed, as a failed regional agglomeration of incompatible interests. It is clear that the current QHC model simply cannot be fixed
3.    Expect the LHIN to try to gut or stonewall any community-led initiatives
The LHIN is an artificial creature. It survives by toadying to those above it and grabbing power from those below. It defines integration in terms of regional consolidation and regards healthcare delivery organizations, even community based services, as its creatures. The intent may have been coordination, but the implementation has been to create yet another monster that consumes resources and impedes genuine collaboration.
4.    The challenge is to find a workable alternative
It is simplistic to seek a return to the old model of a free-standing hospital in Picton. Even if it were legally and financially possible, it would not be cost-effective or improve the delivery of health services unless it was fully integrated into a broader County-wide model of care: the option that QHC has already effectively sidelined through co-opting the PEHA planning process. The challenge is to move forward not backward.
5.    We must turn the Problem into a Solution
Uncontrolled health costs make Ontario very vulnerable. Change is going to have to come, but it will have to start small and prove itself if it is not to be swept into the conventional one size fits all “solutions”.  What is needed is a small scale demonstration that can be tried and then adapted and expanded based on its performance.  Many of us in Prince Edward County have maintained for some time that the County is an ideal place, where that process of change could begin.
6.    The Prince Edward Community needs to act united
The reality is that no-one outside the County is going to take the initiative to change the current situation. The PEHA was a fine idea, but, whatever the denials, it was scuppered by Quinte Health Care with the active connivance of the South East LHIN.

Any new initiative must emerge from the County itself. Pillars for a new Community Health Care Coalition should include: the Family Health Team, the Municipality, the PEC Hospital Foundation, The Hospital Auxiliary, and community organizations  like POOCH, service clubs and other grass-root bodies. The old adage applies: if you aren’t willing to get your hands dirty, the work will not get done.
7.    The Municipality (and its taxpayers) cannot expect a free ride
The Municipal Council has tended to make supportive noises about health care, but to disclaim any responsibility for health care services in the County.
This attitude is not realistic:
a)    The municipality (and its taxpayers) already bears substantial costs related to the McFarland  Nursing home, to the Public Health Unit, and to land ambulance services.
b)    The Municipality is responsible for land use planning which includes zoning, access, and other requirements for health care delivery sites.
c)    The Municipality is responsible for the overall economic and social well-being of the County the availability of good health care services is a critical aspect of this responsibility.
d)    Finally, the Municipal Council is a body of representatives elected by the residents of the County to represent their interests.

A legitimate question to ask: Is the establishment of a sustainable healthcare system in the County sufficiently important to its ratepayers to support a more active  Municipal involvement on their behalf. If the answer is “no” our principles may remain intact, but our services won’t.

8.    The objective of the Project
The objective of this initiative is to offer a workable solution that can be adopted with minimum costs and of precedents created.  It must be offered on a non-partisan basis to Provincial political parties and  politicians  (although it will be helpful if this can take place in an election climate.)

The aim is to work with but not become sidetracked by bureaucrats at any level. It would be wonderful if the LHIN could see how much such an initiative could be supported to its own credit, but there is virtually no chance of this happening.
9.    Some initial implications
It will require a close working partnership between the medical community, the municipal council and citizen volunteers. It will have to be funded within the County and heavily supported by volunteers
a)    It will need to start with concurrence on a clear definition of  the desired outcome.
b)    It will require careful evidence based  research of other initiatives in other places. (Why reinvent the wheel?)
c)    It will require legal advice that government lawyers will respect.
d)    It will require a very strong financial plan and the development of realistic deliverables against which to measure performance.
10.    Organization
It will be important to establish an organization to oversee this project. With the concurrence of the Prince Edward Family Health Team, such an entity already exists in the form of a reconstructed Prince Edward Health Alliance.

-Mark Larratt-Smith  was one of the founders and second President of the Friends of Prince Edward County Health Services. He managed  the implementation of the Price Edward Family Health Team and served as a community member of its Board. He also served a term on the Prince Edward County Health Advisory Council and was the founding Chair of the Prince Edward Health Alliance.