rethinking hospitals


This is Part 2 of 2 about the overcrowded hospital situation in British Columbia.

So since my husband was stuck on a hospital stretcher in a hallway on a nursing unit when he was an inpatient last month, you’d think I’d be in favour of building more hospitals and hospital beds to solve the hallway health care problem, wouldn’t you?

At first glance, having more hospitals and inpatient beds seems like a good idea.  If there was even one extra bed at the hospital, maybe then my husband wouldn’t have to have been cared for in a hallway.  Alas, it isn’t as simple as this. I think building more hospitals with more beds is a misguided solution to this super complex problem.

It strikes me that hospitals have an input and output problem.  There are too many people coming in their doors and not enough people leaving.  This means patients are getting stacked up in hallways like piles of wood because people are not moving through the hospital as they should.  Things get really backed up, like a bad traffic jam or horrible constipation.

Let’s start with input.  People present to the Emergency Department with a problem.  The staff in the Emergency Department are under pressure to move people out of Emergency to alleviate build up of people in the waiting room.  So from Emergency, people are either discharged home or admitted to an inpatient unit.  The constipating problem: If there are no beds on the inpatient unit, people end up in the hallways instead until someone is discharged or moved somewhere else and a bed frees up.

I can almost hear you say: “Well people come to the Emergency Department when they shouldn’t for minor things.  That’s the problem.”  I must pause and say:  If people come to Emergency, they think they are having an emergency or they have no place else to go.  Full stop.  That’s why they are there.

The input problem is that patients do not have viable alternatives to the Emergency Department.  What other health care services is open 24 hours a day, 7 days a week?  Some people don’t even have family doctor – which is open Monday to Friday during banker’s hours anyhow – to care for them.  The Emergency Department becomes their health care.

I don’t know where I’m supposed to go if I’ve broken my leg, am in great pain and it is 8 pm on a Tuesday night.  My son once cut open his palm on a mountain bike ride.  The stuffing was coming out of his hand (ugh gory) and he clearly needed stitches.  I checked the local walk-in clinic’s website and they said they were accepting patients, so I sent him there.  The website was wrong; they were full and not accepting any patients and he got turned away.  He had no choice but to go to the community hospital’s Emergency Department, where he sat for five hours before he got his hand patched up with seven stitches.

There was no alternative place for him to go.  No urgent care, no after-hours clinic, no extended hours at a doctor’s office, no Nurse Practitioner’s clinic, no other walk-in clinic.  Only Emergency.  Believe me, the last place anybody wants to be is in an Emergency Department waiting room.  That’s like the seventh circle of hell.

Provide us with other options when we need non-urgent or urgent care.  (I’m not even sure what the difference is between urgent or non-urgent care. Me, along with the rest of the general public, would need education about where to go when).

While I’m at it, allow Nurse Practitioners and Pharmacists to practice to their fullest scope of practice so we don’t always have to go to a doctor. This would alleviate some backlog.  Give us other options with other professionals.  Right now when I’m sick, I have go to my family doctor (I’m lucky to have one who I can access) or go to Emergency.  Offering alternative professionals would help with the hospital’s input problem.

The output problem is this:  Sometimes an inpatient hospital bed is not the best place for a person to be.  Again, nobody wants to be in the hospital.   The food is terrible. There’s no privacy. It is loud and impossible to get a decent sleep.  But some folks are there because they can’t be discharged safely home.  Or they don’t have a home to go to.  Home care services are scarce, especially if you don’t have the insurance or money to supplement public home care with private services.  Family members aren’t always able to be caregivers.  If people need to be transferred to assisted living facilities for more care, there aren’t always enough spots in the public sector available there.  (And people can’t always afford the care in private facilities).

Fund public home care.  Support and fund family caregivers.  Provide more affordable and creative options for assisted living.

Look, I’m no health administrator who makes $400,000/year.  (I just made that number up).  I’m just a layperson patient who isn’t being paid by anybody.  But I can identify constipation when I see it.  There are too many people going into the hospital and not enough people going out.  Things aren’t moving through as they should.

Most importantly, we have to rethink the whole idea of a bricks and mortar hospital.  Yes, there will always be a need to have a place for people to go for surgery and intensive care. But there are a lot of services provided behind the hospital walls that could be reimagined.

For instance, why do hospitals demand that people go to them all the time?  Why not go out to where the people are instead?  Not every community would need a hospital built because the hospital could come to them.

This could be done by mobile services.  Outreach.  Satellite clinics.  Telehealth and other technology.  Home visits.  Coordination of appointments so patients don’t have to travel back and forth to the hospital all the time.  Navigators to help people find their way in a more streamlined fashion.

Why can’t acute care services that have been historically housed in the institution that is a hospital be delivered in the community in a different way?

You could look at individual communities and figure out what they need.  Lots of babies being born?  Then think birthing centres, instead of making women all drive to the Women’s Hospital in the city to give birth.  Are there lots of people with mental health issues?  Why aren’t there more publicly funded mental health services closer to home instead?

I think we jam a lot of services in traditional hospitals so the services will be publicly funded and fall under Medicare.  The Canada Health Act doesn’t demand we do this.  It is done this way because this is the way it has always been done.  It is time for this to change.

I know there are examples of pockets of these sort of innovations happening, but it is just not enough.  I don’t think we need more hospitals.  I think we need different places that deliver acute health care instead.

Hospitals are a relic of the olden times.  They are a status symbol for politicians, a throw back to the old days when a hospital was a reward for voting for a certain political party.  Constructing a new hospital and then just transferring all the same services into a new building is not an answer.

(Caveat:  I know there are hospitals crumbling into the ground, like St. Paul’s. There are times when hospitals need replacing  Also new space, with lots of light and healing spaces for patients and private rooms is wonderful for both staff and patient morale.  I do not deny this.  But more hospital beds equals more staff.  For the Lower Mainland, it is a hard sell to attract hospital staff because it costs so much to live here. Plus, academic institutions need to keep up their end of the bargain by educating more health professionals. Workforce planning is lagging here in British Columbia.  More beds has a ripple effect that needs to be carefully planned for).

But instead of simply photocopying the old services and putting them in a brand new building, perhaps this would be a good time to look at hospitals are being utilized and reimagine the whole damn health system.  Hospitals are based on a sickness model.  It is time that we broadened our definition of health, think about being truly patient-centred and reaching people where they are at – in their homes and their communities.  Building a billion dollar hospital is not a cost-effective solution to me.  If the input and output problems aren’t solved, there are just going to be patients stacked up again in the hallways of the shiny new hospital.  That won’t make for a very good photo op when the media comes around, will it?

And finally, since I’m on a roll here:  Patients might have good ideas too.  All sorts of patients, not just the privileged ones like me.  Patients have a lot of time to think while they are waiting in waiting rooms and hovering beside their loved ones on stretchers in the hallway.  Why not ask them?  Patients might just have the creative ideas needed for true system re-design.

After all, in Canada, patients are also the taxpayers who fund the health care system.  I think we’ve forgotten that.  As a funder, I demand better service for my money and a say in how my money is spent too.  Shoot for the moon folks.  Patients and the health care workforce are worth it.






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