One thing about our health care system in Nova Scotia: It produces good reports on what to do. It's doing it that's the problem. Now, at the end of a string of studies going back a decade and a half, the one by Dr. John Ross on emergency care nails it once and for all. If nothing happens now, we're really in trouble.
Let's define "we." The challenge Ross lays down is not just to the Department of Health and the administrators, doctors and nurses down the line. It's also to what communities and individuals must do to ultimately make things work properly. It should be read by as many people as possible. It's in down-to-earth language, with a close-up and sensitive touch, and explains better than ever before how the health system works -- and doesn't work. It's an education in itself. To find it, bring up Government of Nova Scotia on the Internet and go to the Health Department. DoH should also spread paper copies as far as it can -- in hospitals, Access Nova Scotia, libraries and elsewhere.
It's not that Ross comes up with a bold new direction. What to do about the big problem, of which overcrowded emergency rooms are the ultimate symptom, has been known for some time. ERs have become catch-alls for everything, and only a tiny fraction of their business is actually emergencies. The rest of the system has to be geared to draw the non-emergencies away, take the overflow of real ones, and reduce the bad habits that get people needlessly to the doctor to begin with.
Rather, Ross gets into the guts of it with specifics on how it can be done, drawing from interviews with medical people from one end of the province to the other, his own experience, and innovations elsewhere -- and some right here in Nova Scotia. For example, the Cape Breton Regional Hospital has relieved its ER greatly by ordering four of its other units to keep a bed free at different times of day to take ER patients -- an illustration of the need to have hospitals operating as one unit instead of as an inefficient bunch of separate units as most apparently do.
But beyond administrative changes, there are the really tricky bits. One of these is the way doctors are paid. This is a tough one, but Ross wants that changed with the aim of producing better public health outcomes. "As it is, many doctors operate as independent corporations not directly accountable to anyone," which militates against the collaborative medicine involving other health providers he says is necessary.
He notes that the American trend of doctors ordering extra -- and by implication, unnecessary -- tests to avoid lawsuits and complaints has arrived. This is costly, and the problem of limiting doctors' legal liability is fraught with problems, but it must be done. Beyond that, he says, "the lack of accountability for how tests and treatments are ordered is equally problematic" -- there's no measurement of the health outcomes of what we're doing. That, too, is a pressing need, as many medical experts have been insisting for some time. (As one physician told me a while back, "I can easily spend $100,000 on one 80-year-old who shows up with multiple morbidities without knowing if any of it will do any good.")
Then there's palliative care. This one's really sticky, and Ross says only that there should be "support for doctors to provide palliative care when medical treatment is not indicated." The wider medical literature indicates that the last six months of life are the most expensive. Huge resources are spent on tests and treatments for the elderly at the end of life when the patient should merely be made more comfortable. When this decision is made, and according to which standards, is perhaps the ultimate hard question.
Then there's the role of you and me and our bad habits. Even a perfectly functioning medical system would not likely keep up with those. The report insists that the system be geared to "better health outcomes." Nova Scotia has among the country's worst rates of obesity, diabetes, smoking, etc., but we're not alone. Similar rises, epidemic in the U.S., are being reported from as far as China and Nigeria. There are studies that say half the incidence of most chronic diseases, even dementia and Alzheimer's, are the products of poor lifestyles. A recent one says even one soft drink a day increases your chances of diabetes by 16 per cent. Let's say that reforming the health system is only half of it. Reforming ourselves is the other half.
Ross found a "non-system" of "multiple specialty groups that do not communicate with each other; multiple delays and hand-offs (of patients), partial data, little accountability, and in the end little evidence that all these investments and activities produce the desired outcomes."
But the report is not a downer. It's a call to action. Ross declares himself "gratified and humbled" by the competence of the people he interviewed throughout the province and their determination to make the system better. "I can say with certainty that the solutions are out there," he says -- but only if the elements of reform he outlines are acted on immediately. Otherwise, the Nova Scotia health system "is nearing the end of its sustainable path." It's now or never.
Ralph Surette is a veteran freelance journalist living in Yarmouth County. This article was originally published in The Chronicle Herald.
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