(Image Credit: Wikimedia Commons; the image is at this link. Used without modification under Creative Commons Licence)
Inadequate capacity in our healthcare system combines with inefficient methods to thwart patients’ entry into the system at multiple points. This is partly because recovered patients are often unable to EXIT from hospitals.
- When patients need to go to a hospital, ambulances are hard to come by
- After paramedics take the patient to a hospital, they cannot leave quickly
- (The above also means that the patient cannot start getting treatment quickly)
- After recovering in hospital, patients often cannot leave quickly
- New entrants to the population struggle to get a family doctor
COST OF CONTROL
After Germany was split into two in the wake of World War 2, a steady stream of migration of East Germans ensued, going over to the West. By 1961, an estimated 20% of the East German population had left. Since the closing of the border in 1952, the easiest crossing point for East Germans was in the divided city of Berlin. The communist authorities responded to this by erecting a barrier – initially a barbed wire fence which was later turned into the infamous wall – in 1961.
The official crossing point between East and West Berlin was called ‘Check Point Charlie’ by the Allied countries.
Having achieved their objective of preventing East Germans from exiting their country, the focus of the authorities there turned (naturally, I think) to prevent entry into it from the Western side. The infrastructure on the Eastern side included a multi-lane shed where cars and their occupants were checked, causing long delays.
The end result was that while crossing over the Wall from one direction was a dream for many due to dissatisfaction with their lives in the East, making the crossing from the other side in a legal manner was often a nightmare as well.
POINT OF CONVERGENCE
Some years ago, I had to take someone to the Emergency department of Brampton Civic Hospital in an ambulance. Soon after the paramedics wheeled the stretcher inside the entrance, they came to a halt. For a brief while, I wondered what the reason could be until I saw that there was a line of eight stretchers ahead of us. I saw the lone counter where each patient had to be registered. The lady at the counter was on the phone. From the distance that I was at, I couldn’t make out what her conversation was about. It went on for quite some time, and some people ahead of us – who had already been showing signs of impatience when I entered – started becoming increasingly restless.
A couple of police officers joined the queue behind me. They had brought in a man who was probably in his 30’s and was visibly intoxicated. From time to time, he yelled loudly in Punjabi. I looked around and found to my relief that most people were unable to understand his profanities. After a while, a middle-aged Punjabi man (without a turban) spoke to this man harshly to the effect that he was being the cause of shame for the whole community. This had the effect of quietening down the inebriated man – for less than 10 minutes. Then he started up again.
In order to use my time for something useful, I struck up a conversation with one of the police officers. I learned from him that the pistol carried by the officers of the Peel Regional Police force is Smith & Wesson M&P9.
From where we were standing, I could see a lobby that was lined at the wall with other stretchers carrying patients. I realized that I was looking at a live demonstration of the infamous ‘hallway medicine’; the patients had been registered but not yet taken to a room. One of these patients, an elderly lady, was calling out loudly for help to anyone passing her stretcher, whether they were hospital staff or not.
After an interminable wait, the person that I had taken there was registered and immediately allotted a small room in the emergency department. Despite its size, it was comfortable and well equipped, complete with a TV set. Sitting on the chair for the next couple of hours, I could still hear the elderly lady’s pleas for help to all passers-by. I wondered why she was kept in the hallway even though she had been registered much earlier.
It was getting late in the night now, and as I dozed off in the chair, my mind went to an experience I had had in the United Arab Emirates.
WINDOWS OF OPPORTUNITY
When I had to apply for someone’s visit visa to the UAE for the first time, people who had experience of the process told me that it was easy and done in a jiffy. Accordingly, I scheduled my visit to the office of the Immigration Department in Dubai on a day when I had half an hour between a few tasks that I was attending to in the city. When I stepped inside the main hall of the building, however, my heart sank – the long, winding queue ahead of me was at least 200 people strong.
As my eyes adjusted to the lighting in the hall (the sun had been blazing at its desert-best outside), I saw that there was a bank of windows for accepting visa applications. Silently, I counted 15 of them.
The requirement for documents was both simple and well conveyed. The staff would check the application and the supporting documents for completeness; if all was in order, they would take the required payment and hand over a receipt to the applicant (which also mentioned the date & time the stamped passport could be collected back). If there was any defect in the application, they would indicate that to the person and hand the documents back. There was no discussion allowed.
The net result was that each applicant spent less than a minute or at the most a minute and half at the counter. With over 200 people ahead of me in the queue, I had finished my business and left the building in less than 20 minutes.
As I recalled this experience, I wondered if the proceedings at the registration stage of the emergency department couldn’t be speeded up by having more counters. It was painful to see all those paramedics and police officers getting stuck in a queue when they could be available outside for more calls. I reflected on how many Canadians view Arab countries as backward, whereas the reality in this particular situation was the exact opposite.
But even after witnessing the sheer waste of resources – which was caused just because nobody had got around to thinking that operations could be organized better – I still did not end up realizing the consequences of this waste.
ANY COLOUR YOU WANT
On January 02, 2022, Peel Paramedic Union tweeted an image from their Dispatch showing the message ‘PEEL CODE BLACK’. Three days later, this story on CTV News explained that ‘Code Black’ means that there is only ‘1 or fewer ambulances available’. Reading this, I briefly wondered about the idea behind saying ‘1 or fewer’; the only number below 1 ambulance is zero ambulances – and at that point, they are not available. I dismissed my curiosity as something resulting from the fact that English is not my first language. The main thrust of the story was that the unavailability of ambulances was ‘due to surge of Covid-19 cases’.
A few days later, however, there was another ‘Code Black’, this time in Toronto, and the story in the Toronto Star attributed it to something else:
“Toronto ambulance ‘Code Red’ caused by hospital delays, not staff shortage, says city”
The story went on to note:
“Paramedics waiting at hospital for up to five hours to “off-load” patients to hospital care was “really the most significant factor leading to those system pressures” [paramedic service head Paul] Raftis told a pandemic briefing …” (Emphasis added)
(Let us not forget here that during these five hours, the patient is also waiting to be treated)
Upon reading this, I thought back to the time I was (with two paramedics) waiting to register a patient. It struck me that a systemic weakness in a critical area of hospital operations was the result of inadequate staffing at a point that always has the potential to become a bottleneck.
There is only one hospital in Brampton, and there were eight stretchers in line ahead of us, each waiting for roughly a couple of hours before the paramedics could be released. We can multiply this by the number of hospitals in Toronto to get a fair idea of the amount of productive capacity kept ‘idling’ while real needs of the city’s residents went unserved.
One argument that gained a lot of ground around the time that the Omicron variant appeared was that the unvaccinated were taking too much of hospital capacity, thus making the crisis worse.
On January 16, Rupa Subramnaya, who often writes for the National Post, tweeted a different picture:
“According to @OntarioHospitalAssn about 41% of alternate level of care (ALC) are waiting to be transferred to LTC. Median wait time to get into an LTC from a hospital is 114 days. This is an insanely high number of people tying up hospital resources through no fault of theirs.” (Emphasis added)
The tweet was accompanied by two graphs showing this data. The latter one is particularly instructive to understand that the situation has been grim for a very long time; over almost a decade, the lowest number of days for a senior patient to be transferred from a hospital to an LTC post-recovery is about 60 days (in the year 2014-15) in Ontario. From that year onwards, the graph shows a relentless incline.
In a nutshell, a large portion of our hospital beds capacity is always tied up because the recovered patients are awaiting transfer to an LTC. If recovered patients have to wait for nearly four months for transfer to LTC before their bed can become available to the next patient, the problem is pretty much baked into the system – the unvaccinated have nothing to do with that structural defect in our healthcare system.
In raw numbers, there were 2,200 seniors awaiting transfer to LTC as on January 12, 2022.
What this invaluable piece of information (I am tempted to call it ‘intel’) reveals is that when we talk about ‘hospital capacity’ and the need ton have more of it, we are missing a very crucial component of our crisis: LTC capacity complements hospital capacity. We can have much more hospital capacity readily at our disposal by expanding our LTC capacity – without adding a single bed to the hospitals.
The cruel irony here is that patients being admitted are unable to get a hospital bed simply because other (recovered) patients are unable to vacate theirs.
As the debate on healthcare swirls, with all the age-old arguments being made over and over again (like the ‘underfunding’ of the system – which is completely false), we are missing out on simple solutions that can deliver immediate results at relatively lower cost.
GROUND LEVEL VIEW
Of course, hospitals are only one part of the healthcare system / crisis. On a routine level, availability of family doctors is also a big part of this puzzle, which I wrote about in my earlier article ‘Bitter Pills’. Recently, I met up with a doctor who has been practising as a family doctor in the GTA for decades. I took the opportunity to get firsthand information on the reasons for this ‘shortage’ of family doctors. Here is a synopsis of the causes:
- In immigrant communities, women have a higher preference for having a lady doctor. They are prepared to wait until they get one, rather than becoming a regular patient of a male doctor.
- Paradoxically, a rising proportion of ladies becoming doctors reduces the overall availability of family doctors because they have to balance their work with their family (including maternity leave).
- Greater preference among new doctors to practise in the major urban areas results in lesser availability in rural & northern areas.
- Family practice is less remunerative, so physicians have a greater preference for obtaining specialization where they can earn more. Therefore, while the World Bank chart may show that the number of ‘physicians’ per 1,000 people in Canada increased by 74.30% between 1970 and 2019 (see this link), that increase does not necessarily reflect in the availability of ‘family doctors’. Plus, disproportionate distribution of ‘physicians’ in major urban centres exacerbates the problem for rural areas.
VETERANS OF DIFFERENT BATTLES
One specific cohort among the Canadians who don’t have a family doctor consists of retired members of the Canadian Armed Forces.
From my discussion with a veteran about this issue, each CAF base has a minimal medical facility. For anything requiring services such as X-ray, MRI etc., they depend on a civilian hospital nearby. Regardless, what we may consider to be the services of a ‘family doctor’ are available on the base.
When CAF members retire, they – and their families – become ‘new entrants’ for the healthcare system wherever they decide to settle down. For reasons mentioned in the previous segment, they face the same difficulties in getting one – but the difference in their case is that they are usually older than the average ‘new entrant’ to the healthcare system. This, combined with the rigors of military life and deployment, means that they may have a higher need for having a regular family doctor without delay.
I believe that there is an urgent need to find a way to give CAF veterans easier access to family doctors, as a way to honour their service to the nation. A simple way to do this would be to let family doctors accept them as patients even if the doctor already has the maximum number of patients allowed within the system. We can explore other options as well.
BEING ‘CAPTAIN OBVIOUS’
The crisis facing us on the front of our healthcare system is multi-faceted, where some of the facets are not of a strictly medical nature (such as the situation with LTC mentioned above). Resolving this crisis is going to require a multi-disciplinary approach. That points to wide ranging public consultation, drawing on the expertise of people from diverse walks of life.
We should begin this dialogue on a war footing.