Putting Out Fires

I’ve worked in a few provincial and federal government healthcare agencies: a pharmacy plan and veterans’ services for example. I understand how difficult it must be to allocate public funds in a rational useful way, keep constituents satisfied and higher-ups happy at the same time, and face hard-to-predict sudden changes in funding and priorities.

I also appreciate that every doctor, nurse, or social worker dedicated to the care of a particular group (premature babies, HIV patients, people on dialysis, vision-impaired) sincerely believes that their patients deserve at least a fair slice of the financial pie, never mind worries that if their program were cut back or closed they might be out of a job. And that it’s not so different in the United States where the allocator of funding is (or is supposed to be anyway) a market rather than political priorities.

The trouble is that the future is not predictable. Crisis occurs unpredictably and often. Spending freezes, key personnel changes, and sudden unforeseen needs happen all the time. This translates to administrators’ attention being diverted without warning from planning and implementing programs to dealing with impossible-looking situations that come out of nowhere: putting out fires.

We face just such a crisis right now in Vancouver where I work. Characteristically we have only rumours to go on, administrators (as I would if I were in their circumstance) being reluctant to reveal specifics before changes actually take place. But in broad outline, there appears to be a large expenditure on a health records system looming, and for some reason the money for this has not been set aside. Clinical programs, therefore, have to be trimmed. Exactly how this will occur is spun (again understandably) as a planned and rational reorganization that will improve efficiency, save costs, enhance service, and ensure a secure future. But if there’s any substance to the rumors the dollar figure allocated to many clinical programs is going to decrease.

Our home-care of frail elderly program is (as I will post on shortly) not unique. Programs caring for homebound elderly (frail, frequent-flyers, end-of-life, disproportionate consumers — call them what you will) that are focused on meeting old people’s individual needs, keeping them away from futile hospitalization and mountains of ineffective drugs, responding to crisis as an alternative to calling an ambulance, all based on a relationship of trust, have sprung up independently in a dozen or more places in Canada and the United States. One of the perhaps surprising but consistent characteristics of these programs is that while giving care that is desired and requested by patients and meeting or exceeding safety and other outcome measurements, they save money.

Shocking isn’t it. A healthcare program that is actually both better and cheaper.

The evidence for this cost-saving coupled with demonstrably better care is accumulating quickly and should now be impossible to ignore. And as we survey the huge variety of health programs served by any big budget like a private provider in the US or a health region in Canada, the combination of better care and lower cost must be pretty hard to find, if not unique to these relationship-based home care programs for frail old people.

Back to the administrators’ dilemma: what programs do we target for unavoidable cost cuts? It seems only reasonable to distribute the bad news more or less evenly. But in reality political and other considerations also weigh heavily. To decrease funding for a pet program of a nationally-known academic, a highly-publicized world-class research initiative, or a ward in the hospital caring for sick children that has recently been featured on TV is asking for the kind of trouble nobody needs when funding is tight, jobs are threatened, hospitals are obviously inadequate, and everybody is looking for someone to blame.

But just a minute. Are we really contemplating cutting funding for a program that is saving money and will continue to do so? How reasonable is it to kill a goose that is laying golden eggs every 24 hours for a fiscal purpose? Even if that goose isn’t exactly a media-darling poster child?

This is just what may be about to happen to our homecare of frailty initiative and dedicated elder care wards and short stay crisis centers that support it. Administrators: bless you for undertaking one of the world’s most difficult and thankless jobs and shouldering the blame for everything that goes wrong.

But for gods sake don’t cut down the money tree. Don’t lop off the only cost-effective branch that has a fighting chance of saving the budget as the baby boomers start to crowd the emergency rooms in years down the road. That would be both a terrible mistake and, when it hits the media, a public relations nightmare.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 30 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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