Change, one of today's most popular buzzwords, was at the heart of a panel discussion on medical care and hospitals last Tuesday, organized by the McGill Institute for the Study of Canada.
Two speakers with much at stake in the debate examined whether changes brought on by budget cuts will improve or harm medical care in Quebec. Dr. Nicolas Steinmetz, Associate Executive Director, Planning, of the McGill University Hospital Centre, presented himself as an advocate of change.
"Hospitals are not statues; statues maintain their permanence by not changing. Hospitals achieve permanence by adapting to the changing needs of society."
The McGill University Hospital Centre, which Steinmetz says will be established in seven or eight years, is a planned consolidation of five teaching hospitals and the Faculty of Medicine. But Steinmetz believes that medical care goes far beyond hospitals.
"The question for today--how can we deliver the best hospital care we can afford?--has two answers. First, by not equating medical care with hospitals, and second, by developing a network of services that would assure that a patient get the right treatment at the right time and place, by the right person."
Today's health care fails on that count, Steinmetz charged, because "we don't really have a system of care; what we have simply grew as a result of the influence of special interest groups, whether they be doctors, administrators, nurses, unions, or universities. It was never designed to do anything, it just grew."
Steinmetz sees the Centre as a model for a future of health care marked by fewer institutions and fewer beds. "Free-standing hospitals are really no longer tenable. In the United States, 60% of hospitals are part of systems and networks of care."
Steinmetz challenged the notion that health care can be measured by the number of hospital beds open. "People get upset that beds are being closed, but we should remember that 98% of health service takes place in communities; only 2% takes place in hospitals."
Far from gutting the system, as some have suggested, the planned hospital cuts are merely trimming the fat, according to Steinmetz. "We now have 340 beds per 100,000 people in Montreal. After the proposed changes, we will have 275 per 100,000. Ontario uses 270, and U.S. studies demonstrate systems that work perfectly well with 111. We can save billions of dollars."
Another trend will be toward far more integrated care. "There will be networks of care which will change the role of the hospitals. CLSCs, private clinics, rehabilitation centres, hospitals and public agencies will all be linked with some kind of information system which will do away with duplication of information. This (system) will be operated on the basis of programs of care, not on departments or hospitals."
It will also include health promotion and disease prevention, "the basis of health, which has not been part of what we have been calling the health care system." Steinmetz says that the orientation of the Centre--and of medicine in general--will also aim to meet the new expectations of today's far from passive patient.
"The emphasis will be on empowering the owners of the hospitals--the people. The patient will participate in his own care, recording certain events, and regularly meeting (with other patients and doctors) to talk about problems and get advice. The system will be based on patient education, demystification of health care, and involving people."
McGill Law Professor Julius Grey, who represents Montreal English-language hospitals challenging the Quebec government's plans to close them down, warned against what he sees as a popular "blind worship of change."
"In the 19th century a new idea would be rejected, simply because it had never been done before. Today we suffer from the opposite problem: if an idea is new or different, we see it as progress."
Grey questioned the very rationale for the cuts that are transforming the health care system. "Canada's productivity hasn't dropped in the past 20 years--it's actually gone up. Why, then, could governments afford health care in 1975, but not today? The answer is that the distribution of money has been skewed--corporate taxes have been cut."
Grey scoffed at the idea that prevention programs can make up for reduced services. "I have some questions to ask governments that want to cut hospitals, and replace them with prevention programs, which didn't pan out in the 1960s and '70s. How can a government seriously do that after having lowered taxes on cigarettes a year and a half ago, thereby ensuring massive admissions to hospitals in 15 years?"
He agreed that the debt situation forces some cuts in the number of beds, "but we have to beware of the closing of institutions. The problem is that governments do not plan for the long run, because they have to be re-elected in a year or two."
Grey concluded with a warning that hasty, short-term decisions usually have irrevocable consequences. "Once an institution is closed, getting it going again means additional expense. When you close institutions in these days of tight money, you can never reopen; you can never get them back."