Premier Tim Houston’s announcement of a new way forward with the building of new health infrastructure last week is indeed good news. Scrapping the last government’s outdated, ill-advised and expensive reorganization of health infrastructure is a year late but better late than never.
Although many unknowns remain, as the announcement was thin on specifics, it is clear that some thought has been given to targeting solutions to needs rather than inventing a solution for a non-existing problem.
Clearly the government needed to make this timely announcement given the crisis faced by people who are literally begging for basic health services. The devil is always in the details, but rest assured there will be fewer problems realizing the government’s vision if the government crafted their plan based on a needs assessment that was developed from information garnered at the coal face and from those who are actually trying to address the needs of people seeking health care services. This indeed will be novel and progressive and its importance cannot be overstated.
Clearly this new plan will have broad public appeal but expectations will eventually run up against reality. It takes time to build new capacity and the greater challenge may be in finding human resources to make it happen. This is where the government and those they have been anointed to manage the health system have a large credibility gap to fill.
The shortage of health human resources was an entirely predictable problem but for the last five decades, government after government pushed the issue down the road and now Mr. Houston is the custodian of those bad historical decisions. Moreover, his managers have to understand that Nova Scotia is not unique and that health human resources have the same supply demand pressures as medication, personal protection equipment, surgical supplies, etc., and as other resources used in providing care, given that each province and territory is bidding for the same scarce resources. Putting your money on recruiting human resources to fix our service deficit will not achieve Mr. Houston’s goals if the effort is not accompanied by a wholesale change in the service delivery model which remains physician centric, disorganized and underfunded.
He might start with establishing a governance framework that actually has content experts that are arm’s length from political influence and focused on best practices that exist in other jurisdictions, and that hold the managers of the system accountable for achieving targeted evidence-based goals.
The “tridemic” (COVID-19, Influenza A and RSV) we are facing has highlighted how bereft our system is. We are in unprecedented times, it is true, but nearly three years have passed since COVID-19 touched our shores and we are more challenged than we ever were. More people have been hospitalized and have died in 2022 in Nova Scotia than the previous two years. We have yet to tally the morbidity and mortality from influenza and RSV.
My former colleagues in the emergency medicine field are reporting increasing difficulty delivering the standard of care they were trained to deliver and which people have expected from our publicly funded health care system.
At the beginning of the pandemic, we heard public health officers state that only three actions would alter the course of the pandemic and preserve the integrity of the health system; masking, vaccination, and prudent social distancing. Recent polling suggests that less than two per cent of Canadians believe the pandemic is a problem and less than 50 per cent believe that vaccination and masking are sufficiently important to them.
These are interesting conclusions given that our hospitals are bursting, classrooms are half full, and preventable deaths are increasing. It is difficult to reconcile Public Health’s advice today with what it was two years ago when we were not so impacted by the tridemic we are facing today.
It is no wonder there is a credibility gap when virtually all emergency department leaders are advocating the return of masking and vaccination to help them cope with the surge and ye government officials sit on their hands.
Primary Health Care remains the backbone of health services in Canada. Government has recognized that primary care has a major deficit.
The reasons for this are complicated by a change in the care delivery model which was not anticipated by health planners. For example, after-hours care for primary care patients (after 4 p.m. and weekends) has been almost entirely transferred to alternate care providers who were not ready for the increased volume leaving emergency departments feeling the brunt of the impact.
Government has tried to respond by increasing the number of Nurse Practitioners and changing the scope of practice for pharmacists but few clinical outcome metrics have accompanied those changes. Many of these initiatives were well meaning but there are chinks starting to develop.
Desperate for a win, government rolled out Virtual Care and has framed it as a panacea for patients looking for health care. The College of Physicians of Nova Scotia published a somber warning last week to physicians involved in this type of service: “The decision by a physician to provide virtual care requires an exercise of professional judgement considering the circumstances and condition of the patient. Virtual care must not compromise the standard of care.
The communique goes on to say: “Virtual care was ramped up quickly to provide access to care at the onset of the COVID-19 pandemic. Over the course of only a few years, it has now become a fixture in our province. While the availability of virtual care plays an important role in providing access to care, particularly for those on the Need a Family Practice Registry, there have been a number of unforeseen consequences.”
“There is public unrest. Complaints from patients regarding their virtual appointment bookings are on the rise. Most commonly, appointment times are missed by physicians, and no follow-up is undertaken to rebook the appointment. In some instances, virtual appointments experience technical difficulties; calls are dropped and then not reconnected. We also hear from patients who want to be seen in person but are offered a virtual appointment only or have been provided with a referral to a specialist located hundreds of miles away in the province.
“Concerns are mounting from within the profession as well. Some common narratives are emerging. Physicians working in strained ERs are exasperated at the number of patients referred to the ER as a result of a virtual consultation but with no urgent or emergent issue. Family doctors have raised alarm bells regarding no follow-up from virtual care consultations as well as no process in place to see patients in person when appropriate.
“The decision by a physician to provide virtual care requires an exercise of professional judgement, which must appreciate the circumstances and condition of the patient. Virtual care must not compromise the standard of care.”
Virtual Care has an important role to play in the continuum of care but government and providers need to understand that a robust quality assurance process is required to guarantee that the service provided meets an evidence-based standard. It is not a replacement for primary care but an adjunct to the care continuum. It will never replace person to person assessments.
It is interesting to note that the Canadian Medical Protective Association (CMPA), the body physicians rely on to defend them in a legal claim against them, has been looking at how physicians are coping with the new resource-starved environment they must work in.
In a recent message to members, they state “managing patient access to limited healthcare resources has always been a reality for Canadian physicians. The public health emergency created by the COVID-19 pandemic has exacerbated existing backlogs, wait lists, and healthcare worker shortages. Physicians are concerned that patients may be harmed due to a delay in diagnosis or treatment owing to resource constraints, and are wary of civil actions and complaints potentially made to their regulatory authority.”
The courts now are willing to consider the resources available to physicians when assessing whether the standard of care was met. “The courts have stated that an assessment of a physician’s clinical care is not based on a standard of perfection, but rather on the standard of care that might reasonably be applied by a colleague in similar circumstances.
“Nevertheless, physicians are expected, within those resource constraints, to do the best they can for patients, and to act reasonably in such circumstances. Physicians should document any efforts to obtain the required resources for their patients (e.g. referrals). Hospitals, for their part, have their own duty of care toward patients, for instance by ensuring that there are systems in place to coordinate personnel, facilities, equipment, and records so that patients receive reasonable care.”
If there are dozens of patients waiting for an acute care bed, some of whom are critically ill, and there is an adverse outcome, is it fair to go after the physician who is unable to move that patient? Where is the accountability framework that holds managers’ feet to the fire when the standard of care is not met? Moreover, where is the transparency? Where are the outcome metrics published? We track hip and knee replacement wait times but do we track and publish how many people waited in the emergency department (after admission) before they were seen by the appropriate service? Do we track their outcomes? It is all well and good for CMPA to advise physicians to document and refer but who really monitors whether it happens?
For the courts to validate that emergency room physicians are unable to deliver the expected standard of care today that is expected and therefore cannot be held to that standard provides the health consumer with more evidence that government is not delivering.
There is no question the government is challenged as it navigates uncharted territory but it remains constrained by precedence. It is time to consider co-locating nurse practitioners, advanced care paramedics, family physicians and social workers in or near emergency departments. If the space does not exist, bring in temporary space to make it happen. People do not care what these spaces look like, they just want to be seen and heard by competent and caring health professionals. Change the triage model so that physicians are the first point of contact for the person seeking help so that a decision to redirect the patient, order an investigation or discharge the patient can be made rather than have the nurse or paramedic relegate the patient to a queue where their condition has the potential to deteriorate.
The government has finally acknowledged what many have been advocating for years; a space for patients requiring alternative levels of care while awaiting nursing home placement rather than have them occupy a hospital bed.
In the past, it has been suggested that hotels be commandeered to address some of these needs of some of these persons needing care with the support of professional staff to assist with their care. Clearly this should be regarded as a hospital decompression strategy until the new promised space is available. Of all of the premier’s announcements last week, the creation of this “transition” space should have the greatest priority because it will have the greatest impact on patient flow and surgical wait lists.
So kudos to Premier Houston for having the gumption to bite the bullet and push up against convention. He now has to build the organization that will deliver on his vision but he has neither all the parts, nor the people in place yet.
Dr. Robert Martel
Cap Auguet