By: Matt Gurney
I have solved the Canadian emergency room crisis. Please send me $47-million.
OK, OK, I’ll explain. This week, the Ontario government announced it was spending $47-million over four years to expand a trial program to over two dozen emergency rooms. The trial had brought some modest but real improvements to the handful of emergency rooms where it had been studied. The goal is to get ambulances back onto the streets faster, reduce wait times for care in ERs and get patients home faster. It’s a worthy initiative and I hope it works.
Thus ends the sober commentary. Let’s get into the primal-scream-therapy phase of this column: we do not need to spend $47-million making incremental improvements. We need to completely reform how the system works, and the extremely excellent news is that we don’t even have to study what the problems are. We know what they are.
Health care is, obviously, a spectacularly complicated system and it has many problems. I don’t pretend to be an expert in most of them. But the chronic delays in Canadian emergency rooms do not require expert-level knowledge. What’s gone wrong from coast to coast to coast in this country has been studied to death and is well understood.
The problem isn’t the emergency rooms. It’s everything that happens next. Fixing the emergency rooms means fixing the rest of the system, both to reduce the inflow of patients and dramatically improve the outflow. This is proving stubbornly hard to do, but is actually really easy to understand.
First, the inflow. Not enough Canadians can get access to necessary medical care and support in their communities. This usually means having a family doctor, and, specifically, a family doctor who actually has the time and resources to properly assess and treat people before they are critically sick. Where someone does not have access to a doctor, or the doctor doesn’t handle the issue, a hospital emergency room can become the only place to actually access health care. There are also Canadians who need other types of care, including addictions care or mental-health care, which is also often difficult to access in the communities. These people too often end up in ERs.
An emergency room is not the right place for these people. It’s also an economically inefficient place to treat them. This is well known. No one disputes this. But even so, the access problems at the community level persist, and the emergency rooms are where they manifest.
The next problem, and my understanding is that it’s the bigger one, is the outflow — getting patients out of the emergency room. Because they need to go somewhere. And too often, there is nowhere for them to go.
Ideally, someone can go to an ER, receive whatever treatment is needed, and then leave. A classic example: busting an arm or a leg, or needing some stitches after a bagel-slicing mishap. Other patients may present at an ER with something that looks serious but ends up being minor. A disaster having been ruled out, that patient is safe to leave and seek non-urgent care.
But a lot of people can’t go home to the ER after an all-clear or a relatively fast treatment. They need to stay for tests, or require admission into the hospital. And that’s where the nightmare begins.
Imagine a patient in a hospital who’s going to be OK, but is going to require some rehabilitation work before going home, to get their strength back. That patient has to stay in a hospital ward until a bed at a rehab facility is available. Imagine an elderly patient who’s in no imminent medical danger, but can no longer care for themselves. That patient stays in a hospital ward until a bed at a long-term-care home becomes available. Imagine someone who is in a hospital but requires long-term treatment for addiction or mental health. That person remains in a hospital ward until a bed in a facility or spot in an out-patient program is available. Imagine someone who can return home, but only with considerable hands-on support during their recovery. That person remains in a hospital ward until there is a community care nurse or team that is able to get them safely back into their own home.
Every single one of those hypothetical patients is, through no fault of their own, occupying a hospital bed that they no longer need. And another patient in the ER remains there until that bed becomes available. A lack of a community care nurse, a delay transferring someone to a rehab ward or a shortstaffed long-term-care facility that can accept no further transfers creates the traffic jam that finally and inevitably ends up in your emergency room.
Until and unless all the other elements of the health-care system are fixed, the emergency rooms are doomed. This is just a straight-up math problem. We cannot throw enough money at emergency rooms to fix this problem without increasing the overall patient capacity of the system not just in our hospitals, but in our rehab facilities, our long-term-care centres and our mental-health agencies. Everyone gets stuck in the ER because there is quite literally nowhere else for them to go.
There are other problems the system faces, including areas where emergency room capacity has not kept up with population growth. There are also areas where a lack of medical staff is forcing ERs to close, sometimes permanently, leaving large rural areas underserved and driving up demand on what facilities do remain open. Many of the facilities we do have are old and need more space and more modern equipment.
And every one of our problems is being worsened by the unavoidable demographic reality of an aging population, with all the increasingly complicated and chronic health conditions that entails. We knew the aging crisis was coming. We somehow failed to be ready for it. Anyone surprised? Anyone?
One thing I haven’t touched on above is what kind of system I’d want — specifically, how I’d want that system funded. I might surprise some people with my answer, but the honest truth is, I don’t care. I really don’t. Expanding our system by raising taxes is an option. Expanding our system by overhauling it to make it more efficient is an option. Expanding our system by diverting funds away from other government programs, while keeping government revenues generally flat, is an option. Moving to a blended public-private system is an option.
And yes, adding outright private-care options for those who can afford it is an option, and, increasingly, the reality. Physical rehab, community care, addictions and mental health support and long-term care are already rapidly available privately for those with means. Emergency care is, for now, the exception. I am increasingly skeptical that that will be the case for much longer.
Every one of those options has advantages and disadvantages and people will love to debate them. Fair enough. But I personally, for the purposes of this column, am taking a pass. How to fund the expanded system we need is a fight we can have another day; the point I want to drive home right now is that only a much larger system is going to save the emergency rooms. There isn’t any other way to tackle that problem and everyone who has looked at this issue for even a moment knows that. We need to all get on the same page about what we need to do before we all start fighting about how to do it.
And we know what we need to do! Build, baby, build. No further studies, task forces or trials are needed. These are the facts on the ground. Until and unless these facts change, Canadians will continue to suffer and sometimes die because of emergency room delays, and wealthy Canadians will increasingly seek out other options for their medical care. This is apparently the kind of advice and feedback governments are willing to spend millions to receive. I’ll assume my cheque is in the mail.
The Line is entirely reader and advertiser funded. No federal subsidies, no bailouts. If you value our work, please consider supporting us by subscribing or making a donation. Donations are not subscriptions and do not unlock paywalled content, but they help keep The Line independent
To contact The Line with a general inquiry or comment, please email info@readtheline.ca. For other ways to connect with us or to follow us on social media, please see our LinkTree.
“This usually means having a family doctor, and, specifically, a family doctor who actually has the time and resources to properly assess and treat people before they are critically sick.”
My buddy’s son graduated from medical school last year. When he entered medical school seven years ago, there were 187 students in his class. This year, the intake at Western was 189.
There is no serious effort to increase the number of family physicians in this Province, or in this Country.
The population of the province is part of the system around ERs. Like so many of our institutions, the modern health care system was built in the 60s for a population with a certain culture. That culture has changed, largely but not exclusively through mass immigration, and so the institution no longer works. All the basic assumptions about how Canadians behave are simply wrong at the population level.
Reform isn't enough. A gut job renovation is the minimum requirement.