- Email: [email protected]
Hospital restructuring comes to Toronto
520
The Journal of Emergency Medicine
HEALTH
CARE
REFORM
IN QUEBEC:
STILL A LONG
ROAD AHEAD
Marc Beique, MD, FRCP Emergency Department, Royal Victoria Hospital, MontrBal, Quebec Assistant Professor, McGill University, Montrkal, Quebec
As in other provinces, the Quebec government has had to “rationalize” the health care budget. Several measures have been brought in including a freeze on physicians’ salaries. But the main thrust of the reform is a strategy to increase outpatient care (the “vii-age ambulatoire” ) . This involves increasing the amount of home care and the accessibility of community-based outpatient medical care. (This is the responsibility of offices and of “CLSCs”, which are community-based organizations offering me& cal, nursing, and social services.) Ambulatory patients are encouraged to use these for minor ailments and for first line medical care. There is also a plan to increase the proportion of day surgery, day hospital, and earlier hospital discharges in general. The reform also involves reducing the total number of acute care beds throughout the province. This will be achieved through hospital closings (and merging) mainly in large urban areas (Montreal, Quebec City, and Sherbrooke) as well as by downsizing hospitals in rural settings. In Montreal alone, seven hospitals are slated for closure; one has been closed already and more will close in the coming months. Three hospitals will close in Quebec City and two in Sherbrooke. Other hospitals will become chronic care centers.
HOSPITAL
RESTRUCTURING
University hospitals are also merging as part of this process. As the first wave of downsizing is taking effect, many are expecting at least one more wave. The effect of this on emergency services is not yet fully appreciated. The fusion of university hospitals is threatening the departmental status that has been achieved in some hospitals. These departments may find themselves back under the responsibility of general medicine departments with all of the implications this has in hospital politics. The debate on the specialty status for emergency medicine in Quebec (which is being opposed by the FMOQ) adds yet another dimension to this problem. Hospital closings may increase the volume of patients using emergency services. The government hopes to offset this by somehow redirecting patients to CLSCs. Even though no numbers are available yet, there is a feeling that the volume of patients is already increasing in large city hospitals not slated for closure. This increased volume is both in terms of patients requiring admission (as would be expected) and in terms of “walk-in/walk-out” patients. The full impact of the reform (as it stands now) will be clearer in the next several months as several closures take place.
COMES
TO TORONTO
Howard Ovens, MD, CFPC(EM) Co-Director, Division of Emergency Services, Mount Sinai Hospital, Toronto Assistant Professor, Depariment of Family & Community Medicine, University of Toronto
Toronto is one of the last Canadian centers to be affected by the hospital restructuring movement that has been sweeping the country. In a metropolitan area of approximately 2.5 million people, there are approximately 25 acute care hospitals all with emergency departments. Canadian hospitals are public/private hybrids; as private institutions, they have their own board of directors and many have long and proud histories. However, they are completely dependent upon public financing from the provincial government. A decade of budgetary cutbacks have resulted in the closure of thousands of acute care beds in the city without any hospital closing its doors. Late in its mandate, the prior N.D.P. (socialist) provincial government appointed a
blue ribbon task force to examine the issue. The final report was delivered after the last election to the new P.C. (conservative) government. The exhaustive report recommended the closure or merger of ten acute care hospitals in the area. Multiple recommendations were made to transfer a large proportion of the non-urgent patients out of emergency departments and back to community primary care resources for assessment. The plan calls for fewer, busier emergency departments (seeing at least 50,000 patients per year), seeing sicker patients in full service hospitals with a full range of support and consultation services. Although most would applaud the intent and final vision of the report, the parts are complex and
521
CAE3 News
interdependent. Many people fear a piece-meal implementation based on political or financial considerations that could destabilize a system which is already struggling to cope. The current government has not committed itself to the specifics of the report. However, they have made sweeping legislative changes to give themselves the power to close or merge hospitals and have appointed a commission to implement hospital restructuring. Cur-
HEALTH
CARE
REFORM
rently, there is a great deal of apprehension and uncertainty throughout the Toronto hospital community. In addition, Toronto hospitals are facing an 18% budget cut over the next 3 years. While the final outcome for individual hospitals and for the system as a whole remains uncertain, the volatile combination of political and financial circumstances ensure that the emergency and hospital care system in Toronto will be radically different 5 years from today.
IN MANITOBA-A Joe Wiatrowsky,
Emergency Department,
STRIKE
IN WINNIPEG
MD
The Salvation Army Grace General Hospital, Winnipeg, Manitoba
Always, in all ways, things change. Alone, the word “change” is ambiguous. The emotional impact generated depends upon the implicit and explicit qualifications of the word. The entire range of human emotion can be evoked depending upon the qualification. Health care reform in Manitoba has been successful in evoking emotion through change, if nothing else. Over the past several months, the emergency medical system has become the focus of intense and rapid change, and the membership is trying to meet the challenges imposed by rapid change in the system. It has been difficult, and the entire range of human emotion has been evoked along the way. Prior to September, Winnipeg had five community hospitals and two tertiary care hospitals providing 24hour emergency coverage. The tertiary care physicians are fee-for-service while the community emergency physicians are remunerated under the terms of a collective agreement. This collective agreement expired at the end of June, and the expiration of the agreement was an important trigger of recent changes. Reform of the health system in general had been ongoing prior to June, but there were no specifics with respect to emergency services other than vague suggestions that change was needed. The collective agreement apparently expired at an inconvenient time for the provincial government. There was no clear agenda for emergency services reform, and the government wanted to postpone contract negotiations. Eventually, their position was an offer of a 2% wage reductiol and a l-year term-the same position it was taking with all recently expired public service collective agreements. In addition, the government adopted a somewhat patronizing attitude, suggesting that emergency physicians just sit and wait while the govemment worked out a new system. The government was not interested in soliciting input from emergency phy-
sicians in any meaningful way. This combination of events led to a withdrawal of services at the five community hospitals. The strike lasted one month, ending at the beginning of October when a conciliator’s report sympathized with the government’s concern of impending transfer payment reductions and its ability to pay. The strike, now known as the government’s “social experiment,” pushed the emergency medical system to the forefront of the reform agenda, and forced the government to address a political issue it was not yet prepared to deal with. Using “data” collected during the strike, and ignoring all previous task force reports suggesting gradual service reform and reduction, the government concluded that it could instead reduce services quickly and significantly. Immediately following the strike, all community hospitals were closed at night from 1O:OO p.m. to 8:00 a.m. Over the next 3 months, the emergency medical system struggled to cope under such a drastic reduction in service. During this time, the public realized that the government’s only clear intention was to reduce service. The continued inability of the government to convince anybody that it knew what it was doing led to a massive public outcry. Through the nurses’ union, the public voiced dissatisfaction through a petition drive that collected signatures from more than 12% of the city’s population. Patient care was clearly being compromised by overstressed tertiary centers and underserviced communities. The government was losing support and credibility. The strain intensified until the government was forced to reopen, in mid-December, four of the five hospitals on a 24-hour basis. The fifth maintained night closure. To demonstrate their attention to the problem, the provincial government struck several committees to address emergency services reform, and again, for the
The Journal of Emergency Medicine
HEALTH
CARE
REFORM
IN QUEBEC:
STILL A LONG
ROAD AHEAD
Marc Beique, MD, FRCP Emergency Department, Royal Victoria Hospital, MontrBal, Quebec Assistant Professor, McGill University, Montrkal, Quebec
As in other provinces, the Quebec government has had to “rationalize” the health care budget. Several measures have been brought in including a freeze on physicians’ salaries. But the main thrust of the reform is a strategy to increase outpatient care (the “vii-age ambulatoire” ) . This involves increasing the amount of home care and the accessibility of community-based outpatient medical care. (This is the responsibility of offices and of “CLSCs”, which are community-based organizations offering me& cal, nursing, and social services.) Ambulatory patients are encouraged to use these for minor ailments and for first line medical care. There is also a plan to increase the proportion of day surgery, day hospital, and earlier hospital discharges in general. The reform also involves reducing the total number of acute care beds throughout the province. This will be achieved through hospital closings (and merging) mainly in large urban areas (Montreal, Quebec City, and Sherbrooke) as well as by downsizing hospitals in rural settings. In Montreal alone, seven hospitals are slated for closure; one has been closed already and more will close in the coming months. Three hospitals will close in Quebec City and two in Sherbrooke. Other hospitals will become chronic care centers.
HOSPITAL
RESTRUCTURING
University hospitals are also merging as part of this process. As the first wave of downsizing is taking effect, many are expecting at least one more wave. The effect of this on emergency services is not yet fully appreciated. The fusion of university hospitals is threatening the departmental status that has been achieved in some hospitals. These departments may find themselves back under the responsibility of general medicine departments with all of the implications this has in hospital politics. The debate on the specialty status for emergency medicine in Quebec (which is being opposed by the FMOQ) adds yet another dimension to this problem. Hospital closings may increase the volume of patients using emergency services. The government hopes to offset this by somehow redirecting patients to CLSCs. Even though no numbers are available yet, there is a feeling that the volume of patients is already increasing in large city hospitals not slated for closure. This increased volume is both in terms of patients requiring admission (as would be expected) and in terms of “walk-in/walk-out” patients. The full impact of the reform (as it stands now) will be clearer in the next several months as several closures take place.
COMES
TO TORONTO
Howard Ovens, MD, CFPC(EM) Co-Director, Division of Emergency Services, Mount Sinai Hospital, Toronto Assistant Professor, Depariment of Family & Community Medicine, University of Toronto
Toronto is one of the last Canadian centers to be affected by the hospital restructuring movement that has been sweeping the country. In a metropolitan area of approximately 2.5 million people, there are approximately 25 acute care hospitals all with emergency departments. Canadian hospitals are public/private hybrids; as private institutions, they have their own board of directors and many have long and proud histories. However, they are completely dependent upon public financing from the provincial government. A decade of budgetary cutbacks have resulted in the closure of thousands of acute care beds in the city without any hospital closing its doors. Late in its mandate, the prior N.D.P. (socialist) provincial government appointed a
blue ribbon task force to examine the issue. The final report was delivered after the last election to the new P.C. (conservative) government. The exhaustive report recommended the closure or merger of ten acute care hospitals in the area. Multiple recommendations were made to transfer a large proportion of the non-urgent patients out of emergency departments and back to community primary care resources for assessment. The plan calls for fewer, busier emergency departments (seeing at least 50,000 patients per year), seeing sicker patients in full service hospitals with a full range of support and consultation services. Although most would applaud the intent and final vision of the report, the parts are complex and
521
CAE3 News
interdependent. Many people fear a piece-meal implementation based on political or financial considerations that could destabilize a system which is already struggling to cope. The current government has not committed itself to the specifics of the report. However, they have made sweeping legislative changes to give themselves the power to close or merge hospitals and have appointed a commission to implement hospital restructuring. Cur-
HEALTH
CARE
REFORM
rently, there is a great deal of apprehension and uncertainty throughout the Toronto hospital community. In addition, Toronto hospitals are facing an 18% budget cut over the next 3 years. While the final outcome for individual hospitals and for the system as a whole remains uncertain, the volatile combination of political and financial circumstances ensure that the emergency and hospital care system in Toronto will be radically different 5 years from today.
IN MANITOBA-A Joe Wiatrowsky,
Emergency Department,
STRIKE
IN WINNIPEG
MD
The Salvation Army Grace General Hospital, Winnipeg, Manitoba
Always, in all ways, things change. Alone, the word “change” is ambiguous. The emotional impact generated depends upon the implicit and explicit qualifications of the word. The entire range of human emotion can be evoked depending upon the qualification. Health care reform in Manitoba has been successful in evoking emotion through change, if nothing else. Over the past several months, the emergency medical system has become the focus of intense and rapid change, and the membership is trying to meet the challenges imposed by rapid change in the system. It has been difficult, and the entire range of human emotion has been evoked along the way. Prior to September, Winnipeg had five community hospitals and two tertiary care hospitals providing 24hour emergency coverage. The tertiary care physicians are fee-for-service while the community emergency physicians are remunerated under the terms of a collective agreement. This collective agreement expired at the end of June, and the expiration of the agreement was an important trigger of recent changes. Reform of the health system in general had been ongoing prior to June, but there were no specifics with respect to emergency services other than vague suggestions that change was needed. The collective agreement apparently expired at an inconvenient time for the provincial government. There was no clear agenda for emergency services reform, and the government wanted to postpone contract negotiations. Eventually, their position was an offer of a 2% wage reductiol and a l-year term-the same position it was taking with all recently expired public service collective agreements. In addition, the government adopted a somewhat patronizing attitude, suggesting that emergency physicians just sit and wait while the govemment worked out a new system. The government was not interested in soliciting input from emergency phy-
sicians in any meaningful way. This combination of events led to a withdrawal of services at the five community hospitals. The strike lasted one month, ending at the beginning of October when a conciliator’s report sympathized with the government’s concern of impending transfer payment reductions and its ability to pay. The strike, now known as the government’s “social experiment,” pushed the emergency medical system to the forefront of the reform agenda, and forced the government to address a political issue it was not yet prepared to deal with. Using “data” collected during the strike, and ignoring all previous task force reports suggesting gradual service reform and reduction, the government concluded that it could instead reduce services quickly and significantly. Immediately following the strike, all community hospitals were closed at night from 1O:OO p.m. to 8:00 a.m. Over the next 3 months, the emergency medical system struggled to cope under such a drastic reduction in service. During this time, the public realized that the government’s only clear intention was to reduce service. The continued inability of the government to convince anybody that it knew what it was doing led to a massive public outcry. Through the nurses’ union, the public voiced dissatisfaction through a petition drive that collected signatures from more than 12% of the city’s population. Patient care was clearly being compromised by overstressed tertiary centers and underserviced communities. The government was losing support and credibility. The strain intensified until the government was forced to reopen, in mid-December, four of the five hospitals on a 24-hour basis. The fifth maintained night closure. To demonstrate their attention to the problem, the provincial government struck several committees to address emergency services reform, and again, for the