Can We Delay Hard Decisions?

Last year, Horizon Health Network produced a five-year strategy called Horizon Health Network and Partners: A Healthier Future for New Brunswick. This is available for viewing on our public website (www.Horizonnb.ca). This document identifies four strategic directions to move us forward. First, we would sustain our commitment to be more patient-focused - placing the patient at the centre of everything we do. We continue to learn what patient-focused really means to patients - empathy, compassion and respect. These are now our primary values.    

Secondly, we want to create centres of expertise to elevate some programs to become more consistent across our network and to become more attractive to talented human resources and research opportunities that gravitate to organizations that strive for quality and innovation. Our very first centre, Aging and Eldercare, is just getting organized.  

Thirdly, over the next five years, we plan to reallocate fifty million dollars of our more than $1 billion in expenditures from institutional spending on facilities, supports and programs that might not be as relevant for the years ahead, to community care (including mental health) and the more complex and expensive care such as cancer, cardiac and intensive care that an older population requires. This third initiative has been paused while Government's Strategic Program Review completes its work. This is necessary as we cannot make changes that save resources to reinvest (as mentioned above) and at the same time provide the same savings to reduce Government's systemic deficit. 

Our fourth initiative, breaking barriers and advocating major organizational change, has been a prime focus in our last year. Our system is moving too slowly in the face of inexorable forces of aging demographics and vastly reduced fiscal capacity. Some of the changes we propose include having long-term care and health care jointly managed by one ministry - like other provincial jurisdictions. We want rules changed within long term care regarding the criteria for special care homes, and the ability of patients to reject first offers of available long term care beds. We want faster changes to initiatives to care for people in the community and changes to the way we remunerate some physicians for some services. Private sector options, with reasonable business/value cases, should be open for consideration.

One change we suggest that has been getting a lot of attention is potential repurposing of smaller facilities. Clearly, hospital bed congestion is most problematic at our larger centres where the highest volumes of patients (from both urban and rural communities) require beds for surgery and other acute illnesses. We rarely hear of bed congestion in smaller hospitals. Much discussion has been on alleged negative consequences. One criticism is that we would be moving these residents away from their family members. The fact is we can likely find, amongst our nearly 500 such residents, many who live near the smaller facilities. Most small hospitals are within 40 minutes of larger centres. 

A second concern is the loss of acute care bed access in the smaller facilities once this transfer occurs. True, if this initiative were to proceed, most acute inpatient care would be accessed at the larger regional centre and some travel would be required. But how often do patients require acute inpatient care in the course of any year? 

A third objection is that repurposing a smaller facility would be the end of a 24-hour Emergency Room in the community. (For context, the absolute minimum cost for an emergency room night shift, with one physician, two nurses and a clerical resource is $1 million annually.) Yes, we would propose reducing hours somewhat in these changes but we need to remember that most small facilities have approximately 5-10 visits in the overnight hours and nearly 70% of all visits are triage level 4 (e.g., headache and chronic back pain) or level 5 (e.g., sore throat, flu). With an informed public, many visits would gravitate to the hours before closing or early opening hours. Alternatively, a regional centre is often within 40 minutes' drive, and, of course, a quality $100 million provincial ambulance system is available. 

A final criticism is that, given the rapidly aging population, the proposal won't permanently solve the problem - we will still face increased pressure on acute hospitals. Yes, we will! That is why dramatic systemic changes, including those mentioned above, need to take place. Now! We are buying time to prepare the necessary changes. To those who say this is not a good solution, we say "What is yours? What do you say to the working father who cannot get in to have a debilitating hip repaired for 18 months? What do you say to the pneumonia-afflicted senior awaiting a bed on a stretcher in the E/R for three days? What do you say to the surgeon who cannot get sufficient time in the operating room to maintain his skills?"

No, not the perfect solution, but the best among imperfect options sometimes is a choice we must make. Do we have the courage to make it?