Once again, the holidays were difficult for Quebec hospitals. Shortly after New Year’s, the occupation rate of many emergency rooms exceeded 150 per cent. Some reached 200 per cent and one Montreal hospital even registered a rate of 250 per cent: For every two available stretchers there were five patients. The seasonal flu added to the system’s difficulties but it’s hard to blame a predictable annual phenomenon for problems that have endured for decades.
Overflowing ERs are a symptom of a deeper problem. Ever more public money has been put into the system but central planning by the Ministry of Health and a myriad of legal and organizational barriers prevent an optimal use of resources. One in five Quebecers still doesn’t have a family doctor. In Montreal it’s nearly one in three. Those seeking a family doctor can wait years, even for priority cases, and the number of these just keeps rising. Emergency rooms therefore become the health-care system entry point for many patients. Over half of Quebecers visiting emergency rooms are assigned a priority level of 4 or 5, which generally indicates a condition that could be treated in a clinic.
Despite all the political and media attention our health-care system has received, and despite the considerable and still growing sums of money injected into it each year, wait times are stagnating or getting worse: The median stay for patients on stretchers is the same as it was 15 years ago, while for ambulatory patients it’s up 50 per cent.
Each year, Quebec emergency rooms receive some 3.7 million visitors. Of this number, around 3.2 million are attended to and treated on site. Others are redirected within the health-care system. But the rest leave without seeing a doctor.
Last year, nearly 380,000 Quebecers — or over 1,000 patients a day — went to a hospital emergency room and ended up leaving without seeing a doctor or being directed elsewhere, according to data from Quebec’s health ministry. That means more than one in 10 patients gave up on receiving care. Yet over one-fifth of these patients had been classified as “very urgent” or “urgent” during triage (Priority 2 or 3), which indicates that their condition “is potentially life-threatening” or “could put (the patient’s) life in danger.”
For the second year in a row, the ministry has tried to reduce emergency room overcrowding with winter clinics. But the 29,000 patients treated by these clinics between January and March 2019 represented just a drop in the bucket among the millions of consultations Quebecers demanded last year, whether in ERs or otherwise. The health minister herself recognized that the contribution of the winter clinics “is insufficient” and “much more is needed.” In sum, our health-care system is unable to meet the demands on it — and the effects of population aging are only beginning to be felt.
Despite health-care spending that is on par with that of the top tier of the OECD, Quebec and Canada as a whole are below the average for these same countries in terms of resources available for patients. No public policy can change this state of affairs overnight. If the government wants to see an improvement, it has no choice but to use its limited resources in the most efficient possible way and do everything it can to lower the barriers that prevent patients from accessing care, even at the cost of upsetting certain interest groups.
Expanding the scope of practice of health professionals, notably of nurse practitioners and pharmacists, could make a difference in the short term. Despite some recent progress, their use is still needlessly restricted when compared with what is done elsewhere in Canada and in other similar countries. The skills of other, non-practitioner nurses could also be put to better use, as has been done for several years now in Northern Quebec.
Other measures will only have a longer-term impact but can at least be started now. Along with the reform of fee-for-service payments for doctors (a method of remuneration that discourages delegation and innovation in their practices), the government should put an end to medical school admissions quotas. A surplus of doctors would be a nice problem but it’s one Quebec is far from having.
Finally, the government must take advantage of the upcoming introduction of activity-based funding in hospitals to entrust the administration of some of these activities to entrepreneurs, all while maintaining the universal character of our health-care system, as most industrialized countries manage to do. This combination has led to better results with equal resources, or to equally good results using fewer public resources, as illustrated by the performance of entrepreneurial hospitals in Europe and by the superior quality of publicly funded, privately run long-term care institutions here in Quebec.
Patrick Déry est analyste associé senior à l’Institut économique de Montréal et l’auteur de « Urgences : quand les patients repartent sans être soignés ». Il signe ce texte à titre personnel.