Three health reforms our government should pursue

This is the first in a potential series of opinion columns about public policy issues in New Brunswick.

 

Premier Blaine Higgs has often said that we need to make do with what we have; maximize the benefit of existing assets rather than building something new. This is something with which I generally agree.

It is very much true in our healthcare system, both as it relates to infrastructure, to human resources, and to points of access for specialized care.  

We have regional hospitals that are overtaxed and in need of more space. In Fredericton, the Chalmers Hospital is currently undergoing an expansion at a cost of over $200 million. They were out of room, but was there a way to make do with what we have rather than build new?

We have a beautiful highway infrastructure in our province and thanks to that, the Upper River Valley Hospital is just 50 minutes away from the Chalmers. It is the newest hospital in New Brunswick but an entire wing is empty. Many day surgeries in the Fredericton region are done at the Oromocto hospital 20 minutes away. If a similar arrangement had been made upriver, hundreds of millions of dollars could have been saved.

This kind of thinking can and should be made around the province. We often hear talk that politicians should make the "tough decision" and close rural hospitals. That is not tough; it is easy, at least in terms of creative and strategic thinking. But if you do that, then what happens? How do you deal with already congested regional hospitals that will face more pressure?

The real tough decision is taking the time to figure out how to reallocate services within our existing infrastructure so that we have a mix of optimally used buildings instead of some overcrowded and some underused.

That will mean some services have to leave some regional hospitals, something that is antithetical to the mandarins in the healthcare system and that's the really tough political decision to make. This won't solve all of our health infrastructure needs, but it will solve most of them at a small fraction of the cost of the status quo where we drive more and more into regional centres in the cities.

In addition to moving services from crowded regional hospitals to rural hospitals with excess capacity, we should also be exploring publicly-funded delivery of services in privately-owned infrastructure. There has been a lot of attention paid to public funding for abortions at Clinic 554 and potentially similar clinics. This would make sense not just from an access and safety perspective but also fiscally responsible management of infrastructure. The same applies to many other services, for example blood work. In Ontario, when you need blood work you don't wait for weeks for a letter to come in the mail advising you that weeks still in the future you can go and queue up for an hour to have blood drawn at a busy regional hospital. Instead, you can walk into any private blood clinic at your convenience without an appointment and be in and out in under 10 minutes at no charge to you, public health care pays the clinic the same way they pay your family doctor.

This also speaks to the need for better access to primary care. Wait times for family doctors is the most acute example of this. Closing access points in rural areas makes no sense. We need more access to primary care, not less. How these facilities are used and re-orienting them to be more focused on primary care does make sense but this must be done gradually in a way that allows for community buy-in and for the rest of the system to adjust to the change. When a community is used to using an emergency room for primary care because proper access doesn't exist, you can't simply close the emergency room. This is not just an issue in rural New Brunswick; many Frederictonians use the Oromocto emergency room for primary care, many Saint Johners use St. Joseph’s urgent care centre, and many Monctonians use walk-in clinics.  None of these are proper access points for primary care as there are no patient records, no continuity of care and no follow ups.  However, we must provide proper access to primary care first, then ensure that those using the emergency room or other stop gaps for primary care are being transitioned and being well served, and only then have a conversation about whether or not corresponding services reductions make sense.

More broadly on primary care, the main challenge is human resources. Our system is built on the notion that a family doctor must be the entry point to health care. This is expensive and creates unnecessarily long wait-times. Other provinces have more fully integrated nurse practitioners to their primary care system. There is also a lot of talk about increased roles for other professionals like pharmacists and optometrists. For the price of one family doctor, we could hire four nurse practitioners and make four times the dent in the waitlist. If routine prescriptions are being filled by pharmacists, that frees up countless appointments for doctors and nurses to see patients who need to see them.

Every election, the New Brunswick Medical Society puts out a call for parties to commit to hire more doctors. Doctors are an important part of our health system but they can no longer be the be-all-and-end-all; due to scarcity of doctors as well as their relatively high cost.  To allow a nurse practitioner to take a family practice, or a pharmacist to bill Medicare will cost a little bit more than doing nothing. But it will dramatically improve access, reduce wait times and be far, far less expensive than solving the problem with more doctors.

The above are all meaningful solutions to primary care challenges in our system.  But what about specialists?

The crown jewel of New Brunswick's health care system is the centre of excellence in Saint John called the New Brunswick Heart Centre. All serious cardiac cases are sent there and that builds the scale to attract world-class surgeons, afford world-class technology, and ensure those surgeons remain world-class by working at a volume to maintain and grow their skills.

We need to do this with more specialized medical services. This invites risk as it requires telling some specialists they may have to move from their current hospital to another that will host the centre of excellence in their practice. Some argue doctors may leave the province rather than move a 100 kilometers within the province. That is a risk and pains must be taken to mitigate that risk. But the alternative is a more expensive system that requires more infrastructure and delivers inferior results. Imagine a province that has an oncology centre as world-class as the heart centre.  The choice should be obvious.

Taken together, a more rational use of our health infrastructure, a more inclusive and expansive use of existing health care professionals, and building and leveraging scale in specialized care could transform our healthcare system. It would lower wait times, lower capital costs and increase quality of care. It will be hard and involve knocking down silos and fiefdoms but this is the kind of health reform our province needs.