The symptom and the disease

On the same morning, the Free Press carried two pieces written from opposite vantage points, arriving at the same locked door.

Charles Bernstein, writing as a gastroenterologist, described a nurse-practitioner program at Health Sciences Centre that gave patients with inflammatory bowel disease somewhere to turn before their illness forced them to an emergency room. It was then not funded to continue, and it ended. A service that had been approved, put in place, and shown to work was allowed to lapse.

Tom Brodbeck, writing as a columnist, described Shared Health, an organization created eight years ago as a fourth layer of administration added to the three the system already had — Manitoba Health, the regional authorities, and hospital administrations. He asked what this layer has done for patient care that those three could not, found no one able to answer, and concluded that the province should either make the case or let the structure go.

One writer watched something that worked disappear. The other watched something no one can justify persist. Their accounts are two symptoms of one disease.

Consider what each account demonstrates. In the first, a program produced results and nothing in the structure was obliged to act on them. In the second, a structure consumed resources for eight years and nothing in the structure was obliged to show what was bought. No decision is fixed to an identifiable office, no one required to answer for the outcome, and no answer owed to any party able to compel a change.

That is the circuit the whole question turns on. Responsibility must first attach to a specific office, so the decision has an owner. That owner must then answer to a party outside its own chain, whose duty runs to the patient rather than the institution, and which holds a real lever able to require a change. Only an answer owed to such a party carries a consequence.

A single patient’s path now crosses Shared Health, a regional authority, a hospital administration, primary care, and whatever community service is meant to receive them next, across separate sites and separate regions. Each body owns a segment. None owns the path. Ask any office in the chain who owns the patient’s passage through the whole, and each points to the segment beside it.

“That patient is mine” is the sentence the structure is built never to require.

That bottleneck is now on the front page, behind it the longest emergency waits on record — more than 13 hours for one patient in 10, and a typical wait, now, of four-and-a-half, numbers unthinkable a decade ago. The ward bed held by a patient who is safe but in the wrong place, while the patient who needs that bed waits, is real, it is well-drawn, and it is still the symptom.

This is why the emergency room keeps returning as the subject. It is not where the failure begins. It is where the failure arrives. A bed that is not there, a program that is gone, a structure that cannot show its worth, each lands in the end on a stretcher in a hallway.

Treating the symptom, in Bernstein’s phrase, will not reach the disease.

Bernstein’s program is the disease in microcosm. It was approved. Its data showed that it kept patients out of the emergency room. And it was held in place by nothing. Improvement that isn’t structurally protected is not retained. It reverts the moment attention moves on.

The remedy now urged is capacity, and it is the right one. Build the other end — more personal-care beds, more home care, community care treated as infrastructure rather than an afterthought, and built around what patients need rather than what institutions prefer to run.

It is correct, and it is not enough, and the same two columns show why. The system has funded cures before. What it has never built is the office that must keep the ones that work.

So the announcements will come, new emergency rooms, more staff, another billion dollars, another executive search with no clear mandate to reach the patient, and each will help at the margin, and none will hold. The disease is a governance circuit that answers only to itself, and nothing in it requires that a gain be kept or that anyone answer when it is lost. Absent that, the same crisis returns under a later date.

Two careful writers named the symptoms on the same morning. The diagnosis they alluded to but did not name is not obscure.

Until a decision has an owner, and that owner must answer to someone able to require a change, the system will keep spending on cures it is built to forget.

Alan H. Menkis, MD, writes from Winnipeg.