Sunday, April 08, 2018

About Hospitals ... and Ian Brodie

So, this week Albertans were treated to a column from Ian Brodie on the subject of building hospitals. Mr. Brodie is a former Harper advisor, so we shouldn't be too surprised that he doesn't especially like the idea of spending public money on projects that he or his companions can't directly profit from.

However, a lot of Mr. Brodie's comments aren't merely rooted in the long standing right-wing desire to privatize everything in sight.  No, they are rooted in some the most malicious ignorance I've ever seen on display - and considering that this blog has been running for fourteen years, now, that's saying quite a lot.

Mr. Brodie writes as follows:
This new cancer centre should mark the end of Alberta's "edifice complex." It should end of our obsession with putting up billion-dollar health-care palaces. 
No one denies Albertans should get excellent care when they need it. But as we adjust to the new realities of having a less lucrative oil and gas sector, we have to get a new perspective on health-care delivery. We can do better by being creative, practical and focused on care, not construction.
His opening thesis fundamentally flawed in the first place.  Anyone who looks at our health care facilities in the province and calls them "palaces" either has never stepped foot in one, nor has any idea about the realities of the buildings.  Being "creative, practical and focused on care" is a lovely bunch of mealy-mouthed words to say "spending money on a building is a waste".
Back in the 1950s, the federal government split the cost of building new hospitals with the provinces. Provincial governments got used to spending fifty-cent dollars to consolidate health-care services in big buildings. That's how Calgary ended up with the Foothills hospital in the first place. 
For decades, patients, families and medical professionals knew that life-saving care came in massive and massively expensive health-care palaces. "Big" became "good" in our minds. And this is the problem. We have developed an edifice complex about medicine. We see a building and associate it with compassion and care. Then, we spend our health-care dollars based on this false premise.
If Mr. Brodie were to step back for a minute, and look at the history of the Foothills Hospital, he might learn a few things.  First off, the main building (the original hospital) is now well over 50 years old.  To say that it is showing its age - in spite of multiple renovations - is an understatement.  It was built in a time when Calgary's population was barely that of what Saskatoon is today.  To its designer's credit, it has served this city remarkably well - providing a city which has grown from a few hundred thousand to well over a million residents with access to care ranging from acute illness (e.g.  pneumonia, influenza etc.) to cancer care and neurosurgery.

Building medical facilities today has to encompass both the needs of today, but to some degree must anticipate the needs of a growing population - either by creating capacity, or planning for future expansions.  Anyone who was walked the rabbit warren that is now dubbed "Foothills Medical Centre" will know that we have done both with the Foothills Hospital.  The grounds now encompasses some 12 buildings, created and renovated since the 1960s.
The provincial government began talking up a new cancer centre for Calgary more than a decade ago. The Tom Baker Centre is aging and won't last forever. 
The city's cancer community mobilized and began pushing for a new cancer megaproject in Calgary. 
Canada's medicare programs are notorious for letting people fall through the cracks. Political priorities, professional silos and bureaucratic politics too often take priority over patient needs. The lobby campaign for the new cancer centre promised it would offer one-stop, "integrated" cancer care. That's a goal worth pursuing. 
But when the quest for integrated care got caught up with our edifice complex, a focus on form displaced the concern about function. Along the way, someone decided that "integrated" care needed a $1-billion building. When oil prices rocketed to $100 a barrel, the province started rolling in dough and the price tag started to seem reasonable.
Mr. Brodie makes replacing the TBCC something that mere "community activists" have demanded.  While the cancer patient community has played an instrumental role in pushing the province on this matter, so have the people who actually work every day in the Tom Baker.  There's a reason for this.  When the facility is bursting at the seams, something needs to be done or not only will patients "fall through the cracks", but practitioners who provide treatment will _leave_ - and the price of that would vastly exceed the relatively finite costs of creating a building.
When Jim Prentice became premier in 2014, he started warning that the province was stumbling toward a fiscal crisis. His prosaic concerns about getting better value for our money ran straight into the passionate desire to do right by cancer patients and their families. And the $1-billion price tag on the new cancer centre.
Prentice kept pointing out that, after 15 years of parsimonious government, British Columbia delivered great services to its residents — including health-care — at a far lower cost. Alberta could balance its books by becoming as careful with public dollars as B.C.

Could we do great cancer care in Calgary for less than $1 billion?
Here's where Mr. Brodies argument starts to fall off the rails.  First of all, Mr. Prentice didn't "challenge us" over building a new cancer treatment facility - he did exactly what every premier had done since (and including) Ralph Klein:  kick the project down the road.  He proposed a bunch of milquetoast changes to the current system, such as creating multiple treatment centres, but fundamentally he kicked the project down the road - AGAIN.

Had Mr. Brodie talked to cancer patients in southern Alberta, he would have learned that much of Mr. Prentice's proposals were already standard practice.  Patients in Calgary routinely find that they having to attend treatment in one of multiple locations - often shuttling between locations for treatment.  For patients, and families, this turns the process of treating cancer into a terrifying, gruelling process.  You are constantly dealing with different doctors, nurses, and other staff (all of whom are doing yeoman's work in extremely difficult circumstances).  This reality makes the emotional toll of cancer treatment all the greater.

But, this "distributed treatment" model has another price.  It affects the doctors and nurses as well.  It limits their ability to share observations, discuss treatment, and generally to ensure that everybody is on the same page.  This is an important aspect in any discipline, and all the more so when we are talking about treating life-threatening illnesses.  Creating additional barriers to communication by distributing the caregiver teams across a wide area is not helpful.

Regarding the claim of "BC delivering great services to its residents", I would want to talk to residents in BC regarding their experiences of the system after the Clarke years.  I have deep suspicions that you would find that those "great services" are great only in terms of metrics, but may have a human price that is unaccounted for.

The original price tag for the new cancer centre was a few hundred million ... in the 1990s.  Inflation, growing population, and changes in the requirements for such a facility are no small contributors to the current price tag.
The city's other billion-dollar health megaproject, the brand new South Health Campus facility, was just opening. Prentice suggested it could house a comprehensive, integrated, best-in-class cancer treatment without the need for an expensive new building. In fact, moving cancer care to the South Health Campus would have cut the timeline for replacing the Tom Baker Centre.
Calgary's cancer community raised a wall of opposition to Prentice. Public rallies were held, and the premier was lambasted for being insensitive. 
Yes, that was part of Prentice's "solution".  Cancer patients and their families already knew what this was - another stalling tactic on the part of a politician.  One that they and their families would pay a heavy price for.  Prentice wasn't merely insensitive, he was ill-informed by people like Mr. Brodie whose conceptualization of health-care would be better suited to warehousing boxes of old documents.

Moving a significant portion of the TBCC functions to the SCHC would have done little but move up the timeline under which the SCHC would have to be expanded.  Mr. Brodie seems to have forgotten that the SCHC was replacing beds that Klein literally blew up in the 1990s.  Further, it addresses the equally critical problem of SE Calgary residents who live along the Deerfoot Trail corridor having in excess of 30 minute travel times to reach a hospital.  Again, Mr. Brodie's arguments fall flat for Albertans who remember the human impact of Klein's approach to health care in this province.
Any building can house a cancer centre, and as the economic downturn led to massive layoffs in Calgary, millions of square feet of office space emptied out in our city's core. Outside downtown, industrial space has flooded the market.
Mr. Brodie's profound ignorance on the subject of treating cancer surfaces here.  No, you cannot say that "any" building is suitable for this purpose.  Cancer requires a wide range of treatment interventions, ranging from surgical to chemotherapy and radiation.  Patients can experience sudden changes in their symptoms which can move them from being treatable on an outpatient basis to requiring immediate hospitalization.  The batteries of tests and treatments that must be provided are not trivial, and Mr. Brodie is foolish to imagine that "any old building" in Calgary could be purposed appropriately.

Another dimension of Mr. Brodie's foolishness is in his failure to understand the sensitivity of patients under treatment.  Most cancer patients are to some extent or another immunocompromised during treatment.  Chemotherapy and radiation both have a nasty side effect of suppressing the patient's immune system.  This means that extra precautions need to be taken both by those who attend such patients, but also in the design and engineering of buildings intended to accommodate them.  Your typical office building's HVAC systems are not designed with this in mind (which is part of why norovirus outbreaks in those building spread like wildfire).  Hospitals are designed with these considerations in mind, office buildings and warehouses are not.
Seven years from now, Calgary will have its new cancer centre. With good management it might just end up providing the integrated, one-stop care that its proponents hoped for. But once the new centre is open, the province will be under pressure to build the next billion-dollar health palace.
Yes, Mr. Brodie, it will.  There are hospitals across the province that are reaching the end of their useful life that require replacement.  Instead of bellyaching about the costs, perhaps you might want to reach into that hat full of "creative thinking" that you seem to value so highly, and come up with ideas as to how we will make those investments.  Far too often today, our conservative politicians complain loudly about the costs, but fail to recognize the short and longer term returns on those investments.  Hospitals are not an "expense", they are an investment.  If the Foothills Hospital main building needs to be replaced because at 60+ years old it has reached the end of its useful life, then let us be thankful for the investment made 60 years ago and the benefits reaped from it, and move on with doing the right thing by future generations.  

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