What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Saturday, January 28, 2006

"First, Do No Harm" or "Forgive Them For They Know Not What They Do"

One of the over-ruling axioms in the medical profession over the years has been: “First, do no harm”. I wonder if the movers and shakers of health care reform, innovation, and all those other wonderful initiatives over the last 15 years or so considered “first, do no harm”. The elimination of some 1500 hospital beds when the population of Calgary was exploding doesn’t speak well for the planners. (using the term loosely). The driving force was to cut costs with little or no thought of the consequences for the sick in our society. If there was a plan, it was simply to confiscate the bedrooms of the community and conscript the loved ones as care givers. Doctors were left out of this planning process since they were labeled as being a “special interest group”. In the last five years doctors are being invited to come back to the planning table. Unfortunately, it reminds me of what someone once told me many years ago: “An expert is someone we call to share the blame”.
A system that is patient centered needs to start with an assessment of patient needs at all levels, starting with the community. Palliative care in Calgary is a good example of a successful program. It started by looking at patient needs and then found that the solutions were positive for patients, AND were cost effective. Resources were put in place in the community along with funding provisions, and slowly the program has assisted palliative patients to be downloaded from the Acute Care Hospitals to the community.
A similar process did not exist for other ill patients.
Ten to fifteen years ago I was instrumental in starting a transitional care unit at the Rockyview Hospital. This basically put patients who were waiting for more appropriate accommodation on one unit. Savings could be had by downgrading the acuity of nursing care but more importantly the specific needs of this group could be addressed i.e physiotherapy, rehabilitation, ambulation, etc. Meanwhile there had been a moratorium on the building of long term care beds (nursing home beds) in the community. When the region realized transitional care beds could free up acute care beds, a process of down-loading patients that still needed institutional care (not ready to go home yet) began, and continues to this very day. The idea certainly has merit, but the point is these transitional patients now take up beds that had been designated as long term beds. The personnel (doctors, nurses, etc) and the tools (laboratory, x-ray, oximmetry) was not in place and stress increased dramatically for patients and caregivers. The unavailability of nursing home beds caused a back-up of patients into the community and home care and community doctors needed to assume responsibility for them. Home care was chronically short of resources, and stress leave among home care nurses became common place.
All of the above was and is, predictable. Ten years ago I recommended that an annual assessment should be done of the impact changes in our system was having on the people at the community level. There are good “tools” that can be used for doing this. A minor attempt is being done at present but the baseline should have been established at least ten years ago. Perhaps there was a need not to know! With few exceptions, the changes that we have seen in Canada over the last fifteen years have been cost driven. In a just and compassionate society the agenda must be “patient needs” driven! The medical community has, for years, excused governments on the basis that they didn’t know any better. The scary thing to me is I think they know exactly what they are doing and don’t really care. Can intelligent people really be that stupid?


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