BC Health Care
The Romanow Report and
the state of Provincial health care
Tom Koch
 adj. prof. Gerontology, Simon Fraser University (SFU).
 adj. prof. Geography (medical), UBC.
 bioethicist, Canadian Down syndrome Society
(resource council).
 assoc. David Lam Center for Int. Communications, SFU.
 dir. Information Outreach, Ltd.
http://kochworks.com
Federal and Provincial
perspectives
Within the next year, federal and provincial
elections will be fought in large part over
the issue of healthcare and responsibility for
it.
And while there is a robust federal debate
over healthcare—funding and scope—there
has been no debate over provincial health
initiatives since the current government’s
election.
Debate
The lack of debate can be traced to:
 Lack of a strong legislative opposition.
 Lack of an educated and watchful press.
 Lack of public venues for debate and
citizen participation.
 LHA amalgamation (Vancouver Coastal
as an example).
The desire to preach to the choir.
The Result
The most extensive contraction of health
service in the province’s history, and the most
expensive, has occurred without debate, with a
minimum of discussion and a maximum of
rancor.
Summary History
The Provincial Perspective
The current government was elected in
2000 on the promise of an open, inclusive,
consultative, transparent service that would
not cut health services but would cut costs,
providing healthcare more efficiently and less
expensively.
Public Support
During the campaign, both the
public and health professionals
agreed on the need for change, that
the system needed fixing, or at
least would benefit from
improvements.
If we could have more for less . . .
Why not?
The history
In April, 2002 the BC government
announced major changes to the
infrastructure of the provincial health
care system.
Rationale
One goal was to restore public faith in
provincial health care BC.
“We can never again let the system run down
to the point where people lose confidence in
health care.”
H. McLeod, Vancouver-Costal Health
Authority interim CEO.
Province Newspaper, 24 April, 2002, A4.
To Build the system . . .
Financial: To decrease cost by at
least $550 million without a loss
of service.
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•
•
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This required:
Increased efficiency,
Economic sustainability,
Increased user confidence,
Health worker support.
B.C. demographics
The promise of more for less was made with
full knowledge of BC’s population trends.
Increases in most jurisdictions meant more
service would be required in all parts of the
province, and especially in its most
populated, southern districts.
The provincial reality
Courtesy CHSPR: BC Health Atlas, 2002.
The Provincial Result
The result has been less for more . . .
less service at a greater cost during a
period of rapid population growth.
There is less public confidence and
worse relations between the government
and the health professionals who
provide bedside service.
Service Summary
B.C. hospital service capacities have decreased
by between 8 and 12 percent overall.
The closure of hospitals, ER’s, and nursing
homes has increased pressure on remaining
institutions.
Closures may have increased both systemic
costs (Lin, 2001).
budget cuts
Changes Resulting
Removed from the BC system by 2004:
• >862 acute care beds.
• 9 to 12 ER’s.
• >10-12 hospitals.
• >1,890 long-term and extended care beds.
• One or more rehabilitation centers.
The “restructuring” has been a wholesale contraction.
Results in patient days.
Put another way, in the language of
“patient days” service, this is at least
11.4 % of patient days at full capacity.
At 85 % capacity the reduction is
approximately 10 percent. This is well
below OECD median levels.
Hurrah! Opps
Great: Less persons in hospital is more people
at home with lessened noscomic illness. . . .
if decreased patient days was accompanied by
increased homecare services and support. It
would be good if it did not also represent
persons sent home from hospital who needed
to be hospitalized, if all those who needed
hospitalization received it.
Communities most
affected:
Communities with hospitals that have been
closed/downgraded:
Ashcroft
Delta
Kaslo
Summerland
New Westminister
Castlegar
Enderby
Kimberly
Sanich
Clearwater
Ft. St. James
Mission
Victoria
Vancouver
Effect of hospital closures
• Increases pressure & costs for remaining institutions.
• Downloads costs of travel on patients, patient families.
• Likely increased length of patient stay at referral
• hospitals (Lin, 2002).
• Decreased chances of survival in some health
situations.
• Loss of staff to BC health system.
• Decreased income/livability in local/regional
communities.
• Decreased long-term desirability of a region.
Vancouver-Coastal: Effect
VGH Status 2000-2001:
662 patient days per 1000 pop. age
adjusted.
= 1.8 bed per 1000 pop. age-adjusted.
= 2.1 beds per 1000 pop. age adjusted
@ 85 percent capacity
2003
587 patient days per 1000 pop. age
adjusted.
= 1.6 beds per 1000 pop. age adjusted.
= 1.9 beds per 1000 pop age adjusted @
85 percent capacity.
Effective results:
Wait lists/wait time
Wait lists for essential, non-critical
surgical procedures (hip replacement,
for ex.) have at least doubled.
 Wait times for beds have increased.
 Wait times in many Emergency rooms
have increased.
 Wait time for diagnostic procedures and
specialist referrals has increased.
Changes: Emergency Rooms
Communities with ER’s that have
been eliminated or downgraded:
Chemainus
Delta
Enderby
Hope
Castlegar
Kaslo
Mission
Richmond
Summerland
Port Moody
Greater Vancouver
Effect on ER Service
•Increased travel time may decrease survival
rates and increase length of stay.
• Travel costs downloaded on patient.
• Emergency service response time decreases as
distance from nearest ER increases.
• Pressure on remaining ER’s increases.
• ER waiting times increase.
• Decreased response capability in cases of
disaster or epidemic.
The flaw:
The Inelasticity of demand
Demand is relatively inelastic.
93 percent of all hospitalizations
are unavoidable (Lin et al. 2002).
They are required if patient life and
life quality is to be maintained.
Delay may result in longer
hospitalization in the end.
All changes occur within the context of this relative inelasticity.
Networks
and the ‘domino’ effect
Because demand is relatively inelastic, and
service therefore mandated, closure of one
institution places pressure on those
remaining, and on other parts of the system.
Money saved in one place must be spent in
another, or downloaded to the patient.
Savings are thus typically illusory.
Referral Centres
Impact is greatest on referral centres that receive the
most complex cases and serve simultaneously as local
and district hospitals. VGH, for example,
serves (a) Vancouver (b) Greater Vancouver
(c) Vancouver Coastal and (c ) the province at large.
Fewer hospitals in outlying areas increases pressure
on VGH. Downgrade of services (emergency and
acute) at distant hospitals increases pressure at
tertiary and higher level centres.
Specialty Centers
Similar problems can be seen at other
provincial referral centres. For Example:
G. F. Strong: Spinal Cord Injury
neurological
traumatic brain injury
Closure of Skeleen Village, a TBA
rehabilitation facility.
Sick patients travel further
B.C. standards in this area do not compare
favorably with even those in the U.S.:
1-hour travel time to Emergency care for BC
citizens.
2-hour travel time to Acute care service.
Changes have increased distance to service in
most areas, urban and rural.
Hidden Costs
The necessity of sending some patients
to Alberta or U.S. medical institutions
for urgent treatment is a hidden cost
of the B.C. system contractions.
Stories abound but no analysis of the
system cost—or life cost—has been
reported.
Management and style
The B.C. government has approached the
business of health care by transforming
healthcare into just another business. It
isn’t, neither economically nor socially.
Business/health models
“Just in time” manufacturing
modes do not serve in public service.
Health care requires slack and redundancy if
emergencies (epidemics, major accidents) are
to be handled). Short-term cost-benefit
accountancy is costly, and may result in
diminished service.
The B.C. Government
argument
The B.C. Government has blamed health care cost
increases on
 the federal government and its failure to
adequately fund health care and
 Increasing labour costs for care providers
“the continued escalation of health care costs is
not sustainable,” Ministry web site.
Spending has Increased
“In BC, we're spending over 42 per cent of the
total provincial budget on health care, with $2
billion in new funding added over the past three
years.”
B.C. Ministry of Health web site accessed 8 May 2004.
http://www.healthservices.gov.bc.ca/bchealthcare/pressure.html
Federal Monies
BUT federal monies for provincial health
systems have increased, in part as a result of
the Romanow Commission and its debates.
This has been a boon unacknowledged by
B.C.’s government in public or on its website.
Labour Costs
The government has blamed rising
costs/declining services on patient-related
employees:
“We now spend $10.7 billion a year on health care.
Of those dollars, almost 70 per cent goes to
compensation for health care providers and support
workers . . .the continued escalation of health care
costs is not sustainable.”
B.C. Ministry of Health web site accessed 8 May 2004.
http://www.health services.gov.bc.ca/bchealthcare/pressure.html
Increasing cost structures
But among the most significant areas of
cost increase have been:
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restructuring itself.
management salaries.
non-patient care salaries.
advertising.
Non-labor costs:
restructuring.
VCHA financial statements peg the cost of the
restructuring in 2002-2003 at $20.2 million for
VCHA alone. Similar costs presumably occurred
in other Health Authorities.
“Restructuring costs: In the current year, management
has recorded an expense of for restructuring costs in
the amount of $20.2 million. The restructuring costs
consist of severance and related costs that are
anticipated to result from the restructuring of the
VCHA.”
From: 2002/03 VCH financial statements
Increased Management
Costs
The number of employees earning more than
$75,000 a year at VCHA alone rose from
2002 to 2003 by about 47 percent. The cost
was about $55 million.
From: 2002/03 VCHA financial statements
Non-patient care costs
These are not cooks, dietitians, electricians,
laundry workers, lab technicians, floor
nurses, etc. They are financial analysts, risk
assessment supervisors, managers, PR
personnel, etc. The promise of money “going
directly to the patient” is unmet.
Severance—non-patient
care personnel
In addition, there were 34 severance
agreements made between Vancouver Coastal
and its non-unionized managers in 2002-3 for
between 1 and 18 months compensation. An
unknown but significant number of managers
were on paid stress leave as well.
Long-term costs
Hidden as well are unconsidered but real
long term costs of the restructuring to the
BC economy:
 Loss of jobs to economy.
 Loss of secondary revenues.
 Loss of trained, stable, local population.
 Increased costs elsewhere in system.
 Loss of individuals to work force.
Lack of Consultation
Promises of openness and consultation have
been unmet. The changes, while fundamental,
have occurred without public debate,
discussion, or citizen discussion. There is,
however, a carefully constructed, provincial
health services web page on the Internet.
Public Advertising
Instead, the government has used paid advertising
as its principal medium for discourse. In two
separate campaigns the health ministry has spent
over $900 million on advertising promoting its
“restructuring.” This does not include the cost of
“branding” of LHA’s, web page design, etc.
Branding healthcare
The result is precisely that of a private
corporation (Phillip Morris, perhaps)
repositioning a product it wants to sell to the
public. It appears to be a U.S. model of
private health and private business
transposed into a Canadian provincial
setting.
Health care overhead: U.S.
The U.S. experience in private health care
suggests a management overhead of at least
20 % of total cost of service. It is a minimum
inevitable with privatization . . . and
apparently with the B.C. government’s
“business” model.
Timing
Timing of changes has been rapid and without
thought to human consequences or long-term
planning necessities. As one minister said,
patient problems are the “sawdust” that
accompanies any “renovation.”
Clearly, changes have been rushed and therefore
implemented without adequate safeguards.
Assisted Living
As SFU’s Charmain Spencer notes:
“To date, consumer input and influence have been
noticeably absent from the development of the
assisted living mode. Perhaps not surprisingly, the
resulting health, safety, and tenancy safeguards . . .
have been minimal.”
Spencer, C. 2004.
Summation
Promised but unfulfilled by the current
“restructuring” are the following goals:
 Less expensive health system.
 More comprehensive health system.
 Shorter wait times for “elective” surgeries.
 Better labour relations.
 Restored public confidence.
 Public transparency.
Outcomes
The results to date have been:
 Waiting lists for common procedures
have doubled or trebled.
 Service has decreased in many regions.
 Labour strife has increased.
 Costs have increased.
 Public confidence is diminished.
Underlying assumption . . .
Scarcity of resources is a limiting reality.
It must be met by:
 rationing of services.
 decrease of services.
 increased efficiency of existing (remaining)
services.
Scarcity is an outcome
Scarcity is typically a
condition we create, an
outcome and not an
Inherent limit.
Current policies have
created scarcity, or
increased it.
Tom Koch:
http://kochworks.com
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Book Titles 1990-2004
The Wreck of the William Brown: A True Tale of Overcrowded Lifeboats
and Murder at Sea (Douglas & McIntyre, 2003; McGraw-Hill, 2004).
Scarce Goods: Justice, Fairness, and Organ Transplantation (Praeger Pub: 2001)
Age Speaks for Itself: Silent Voices of the Elderly (Praeger Pub: 2000)
The Limits of Principle: Deciding Who Lives and What Dies (Praeger Pub: 1998)
Second Chances: Crisis and Renewal in Our Everyday Lives (Turnerbooks: 1998)
The Message is the Medium: Online Data and Public Information (Praeger Pub:
Watersheds Stories of Crises and Renewal in Everyday Life (Lester Pub.: 1994)
A Place in Time: Care Givers for Their Elderly (Praeger Pub: 1993)
Mirrored Lives: Aging Children and Elderly Parents (Praeger Pub: 1990)
The News as Myth: Fact and Context in Journalism (Greenwood Press: 1990)
Journalism for the 21st Century: Electronic Libraries, Databases
and the News (Praeger Pub: 1991)
Creating a Cycle Efficient Toronto (Toronto City Cycling Committee) 1992
Six Islands on Two Wheels: A Cycling Guide to Hawaii (Bess Press: 1990).
Selected references
• Cohen, L. A. Manski, R. J. Magder, L. S. Mullen,s, D. Dental visits to hospital
emergency departments by adults receiving Medicaid. J. of the American Dental
Assoc. 133, 715-724.
• Koch, T. 2001. Scarce Goods: Justice, Fairness, and Organ Transplantation.
Westport, CT and London, UK: Praeger Books.
• Lin, G. Allan, D. E. and Penning, M. J. 2002. Examining distance effects on
hospitalizations using GIS: A study of three health regions in British Columbia,
Canada. Environment and Planning A 34, 2037-2063.
• Lowe, J. M. and Sen, A. 1996. Gravity Model Applications in health
Planning: Analysis of an urban hospital Market. Journal of Regional
Science 36:3, 437-461.
• Mahew, L. D. Ribberd, R. W. and Hall, H. 1996. Predicting Patient flows and hospital
case-mix. Environment and Planning A 18, 619-639.
• Morrill, R. 1974. Efficiency and Equity of of Optimum Location Networks,
Antipode 6:141-46.
• Moscovice, Ira. 1999. Quality of Care Challenges for Rural Health. Minneapolis,
MN: U. Minn. Rural Health Research Center, 7.
• Shudd, S. 1996. The Impact of Travel on Patient Outcomes. Dissertation: Yale
University.
•Spencer, C. 2004. Seniors’ Housing Update 13:1. Simon Fraser University
Gerontology Research Center.