November 21, 1996

New health care model should be accessible, innovative and customer-oriented

Dr. Nicolas Steinmentz of the McGill University Health Centre

Dr. Nicolas Steinmetz is Associate Executive Director (Planning) for the McGill University Health Centre, which this month begins a planning process involving 230 people, both health care professionals and patients. They are members of 20 panels, each of which will study different areas of care such as transplantation, geriatrics, mental health and infectious diseases. The process was officially launched on November 8 with a conference on the topic "21st Century: A New Vision for Health Care."

The MUHC is a proposed amalgamation of McGill's Faculty of Medicine and four of its affiliated hospitals: the Montreal Children's, the Montreal General, the Montreal Neurological Institute and the Royal Victoria.

What are the goals of the current planning process?

We have a unique set of opportunities in front of us: the public is ready to accept major changes in the health care system, many factors are pressing for a drastic change, and we have the academic freedom to reinvent the way we provide health care.

We have to recognize that we are pioneers in what we are trying to do--we don't know of another project quite like this. We might not all be there to benefit from the success of this venture, but we are planting seeds for the future.

We also want to make the point that we need to be advocates for change, for innovation, open-mindedness and learning, not only in the McGill network, but in the global network--Montreal in the Quebec context, and beyond; we have been contacted by people from several countries to discuss what we are doing.

Finally, we have to capitalize on the key characteristics of our planning process. We want to ensure that it is consultative and multidisciplinary, that the community is well represented, and that it is patient focused.

How much influence will the planning process have over the final product?

I know there is a lot of scepticism; people are saying that we have already made up our minds about what will be done, and it doesn't seem to matter how many times I deny it.

The 230 people involved in the planning process will be able to confirm the fact that the fix is not in, and it really is these people who will define the future of this centre. Their work will lead to the conclusions about how many square feet, or how many beds we will need.

However, the emphasis will not be on beds, but on programs of care. People who are ill or injured don't need a bed; they need care. Where and how this care is best provided, using the best knowledge we have and applying our technology to the best advantage, and using interventions that have demonstrated their value and usefulness--those are the considerations which will determine what the MUHC will be and do in the future.

What is it you expect from panel members?

The members of the planning panels are receiving information from around the world, from trends in Quebec and elsewhere. They will put that information in the context of changes in demographics, and expected changes in science, diagnostics and treatments, for the treatments they are familiar with, because they are the experts.

They are the ones who treat people with particular problems, and they can tell us what the future of each discipline, and each treatment, is likely to be.

I was just at a meeting in which a vascular surgeon told us that the average length of stay for their patients at the Royal Victoria Hospital and the Montreal General Hospital is 12 days. He thinks they can reduce that, within a year, to six days. If that's true, we would need only half the beds they have now for these patients.

Will patients be part of the process?

We have a patient or former patient on each panel, and no doubt they will challenge us. They are people who have had the illness or condition being addressed by the panel, and they will tell us what the experience felt like, and how they think we can change the system to make it better for the patient.

The stated philosophy of the MUHC is to follow a "patient- focused" model. Is there a difference between that philosophy and what has been done in the past?

It is very different. Right now, services are organized to meet the needs of professionals, of union contracts, of service providers. Clinic appointments are set from morning to late afternoon, not usually in the evening, but most people are working and find it difficult to take time off work to go see a doctor or to get a diagnostic test done.

Stores have evening hours, to meet the needs of the consumer. People ask "Why don't you have clinics on Saturday?" or '"Why can't you do this near my home?" If we were a business, and we saw the patient as a customer, we would do things differently.

Do you expect any resistance from the professionals?

I don't really see any conflict. We have to remember that the doctors, nurses and technicians go into the health care profession because they want to help people. They want to do something good, but they end up in a system that is managed in a way that doesn't always place the highest priority on that objective. Many don't like the system, but have been essentially powerless to change it.

Since we are in a time of confusion, and a time in which much pressure is being put upon us from a million different places, we have a real opportunity to rethink. So we are rethinking, with the participation of those who provide care and those who receive it.

If the system doesn't serve health professionals or patients well, why has change been so difficult?

We spend more on health care and on hospitals than any other country with a system like ours. But it's hard to change the system because it exists under so many constraints, such as contractual agreements and governmental regulations.

We drown in regulations in hospitals, but that is one of the things that will have to change. The minister of health is engaged in an initiative to reduce hospital and health care regulations, and I am optimistic that his initiative will be sucessful.

Rules and regulations define the past, not the future. By the time you achieve a consensus on some regulation, events have moved on, new information is available, and we really ought to do it differently. We have to find a way in which necessary changes occur in a regular, continuous manner without these horrendous shakeups every five or ten years.

One speaker at the conference said that hospitals will focus on very ill patients; the model will be for the frail 70-year-old, rather than 30-year-olds.

Hospitals in the future will be more of a last resort for the very ill, and not the first place you go. Hospitals will be for the most ill or seriously injured people, who require the largest collection of different skills, or a skill which is relatively rarely needed. It's a different idea than at the moment, in which a hospital does a bit of everything for everybody.

Where will people who are less gravely ill be treated?

They will be looked after either in day treatment centres, day surgery centres, or CLSCs. What we now understand as a CLSC is going to change a lot, too. They will have a different mix of professionals; it wouldn't surprise me if they developed a certain number of beds, for respite care, or for observation before the patient is sent elsewhere. We now have CLSCs with birthing centres; that's not something they had until a few years ago.

Other speakers emphasized a focus on alternative therapies and advising people to adopt healthy lifestyles. Will that be a major MUHC focus?

Again, the planning panels will tell us what they think, but, for example, Harvard University has a whole department, with full time professors and staff doing research and teaching on so-called alternative medicine. Maybe we should look at what we could and should introduce into how we do our business. I expect that this is one of the things we will seriously consider.

In most areas, I expect they would say that more research is needed, to carefully evaluate alternative treatments, but we also need to evaluate what we already do. There is a lot of evidence suggesting that many treatments the medical profession uses now are not really effective.

Some people have suggested that the money won't be there--that the government won't be able to fund the MUHC. Is the planning process partially intended to find a way to make it financially feasible?

The most important goal is to try to design a system of care we can provide which best meets the needs of people, and at the best cost. After that is established, we will see what is possible within the budget that we have. We will have panels which will look at whether it makes sense to build a new building, or whether we should renovate or expand what we have now.

It seems many aspects of the MUHC are still up in the air.

This is a very complicated undertaking. If it takes a car company several years to design a new car, it will take a little bit of time to figure out how our institutions will best meet the needs of society. So far, we're making excellent progress; the planning process was only started last year, and the services part of it will be finished in April.

What's the timetable for the next several years?

We hope that all the reports will be written and approved by our various internal bodies by next September, so we can then discuss them with the Regional Board and the Ministry of Health. The rest will depend on whether we have to expand our current facilities, or build a new building. So we don't know how long it will take, but our goal is to establish the centre in eight years--by 2004. It could be sooner or later than that.

Is there still a chance that the MUHC will never become a reality?

Nothing is for sure, but I think this will happen. We have a lot of good people, the time is right, the need is there, we have wide participation, and we have a mechanism to build consensus. We are not a bunch of crazies marching off to do something loony.

Interview by Sylvain Comeau