Medical care — done right, it’s all connected

Opinion

Hey there, time traveller!
This article was published 21/12/2024 (284 days ago), so information in it may no longer be current.

Health-care systems are complex beasts. While it may seem simple to break them down into their major parts (funds, policy, how the funds are spent) and people (human resources), the interactions between them are very complex. For almost every change, there is likely to be an unexpected reaction somewhere in the system; where you press on one side of the balloon, the other side bulges out to compensate for the loss of space inside the balloon.

The current crisis in the Manitoba health-care system has developed due to multiple interacting challenges. While our population has grown by 25 per cent since 1995, with an increasing group of over 85 years olds due to the aging of the boomers, the number of hospital beds in Manitoba has remained static.

In addition, there are more elderly, infirm people seeking care at fewer emergency departments, coupled with less access to beds to admit those in need of hospitalization. Approximately 30 per cent of emergency department visits are avoidable because they are more appropriate for care by a family physician.

This has put huge pressure on our emergency departments, which were reduced in number in 2018.

Pressure on hospital beds means patients are discharged to the community to be cared for by family doctors earlier in their recovery.

These patients have often been diagnosed with multiple chronic conditions and are likely to be prescribed multiple medications. They need monitoring of their illnesses and often need adjustment of their medications.

To do this, their family doctors must order laboratory tests and imaging that need to be interpreted and acted upon, leading to increased administrative work between visits. Because these are patients who, in many cases, would have still been in hospital if there were enough beds, the decisions that need to be made are more complicated.

The impact of this increased workload on family doctors’ limits access to primary care for others. This has contributed to burnout amongst family doctors who are struggling with the responsibility of caring for sicker people in the community and the increased administrative burden associated with this work.

In 2018, we had a system designed for the 1970s that needed updating. While the motivation for the 2018 health system transformation was clearly a cost saving endeavour rather than an attempt to improve patient care and health outcomes, any potential benefit was compromised by the inept implementation of the reforms and interrupted by the COVID pandemic.

This perfect storm, with dramatic increased demand for the emergency and hospital systems coupled with the cutbacks of transformation, led in part to the current crisis we face.

Transformation cutbacks led to nursing dissatisfaction which coincided with the increased demands for care. The response was mandatory overtime for nurses which led to more burnout and dissatisfaction.

The resulting shortages led to the mushrooming of private nursing agencies where nurses have increased autonomy over their working hours. The public system is now dependent on private nursing agencies which charge the system significantly higher fees, with most of the benefit going to the agency owners.

Another pain point in the system has been the inability to meet the demands for surgical procedures, particularly for so called “elective” surgeries.

Manitobans suffer from pain for way too long while waiting for orthopedic surgeries. The “band-aid” solution of sending patients out of province for these surgeries resulted in the missed opportunity to build local capacity for the future. Rather than investing in our local capacity to provide services in the future, we added to the capacity in other jurisdictions.

So, how do we address the health-care needs of Manitobans for the future?

We need a balanced approach between meeting the urgent issues of today while building our capacity for a sustainable future. It all starts with primary care. Last year a pan-Canadian project asked Canadians what they want from primary care (OurCare.ca). The Manitoba round tables provided responses that were consistent with other jurisdictions.

Manitobans want ready access to primary care provided by interdisciplinary teams. They want access to their medical records, and they want culturally appropriate care. All of these are consistent with a sustainable, efficient primary care system. An efficient and accessible primary care system can help keep people out of hospital. People who see the same group of primary care professionals over time (called continuity of care) have been shown to have better health outcomes. Getting care from providers who know us as individuals, not just the diseases we suffer from, builds a trusting relationship.

Facilitating the change to more team-based care requires supportive policies.

Building those teams will take time. We will need more nurses, community pharmacists, physiotherapists, Indigenous elders and other providers working in primary care. We will need to train these professionals to work in the community with the family doctors and nurse practitioners who currently provide this care as well as increasing the number of physician assistants working in primary care. The Manitoba approach to team-based primary care, called My Health Teams, needs significant enhancement if we are to meet population needs.

A good first step would be a five-to-ten-year plan which addresses the short-term needs while building the system for the future.

Alan Katz is a practising family physician and a health services researcher.