Tuesday, January 17, 2012

Sober second thought about Saskatchewan's healthcare transformation plan

There's many a slip 'twixt cup and lip.

Thanks to Mary "Wet Blanket" Smillie for cooling my ardour over Saskatchewan's healthcare transformation plan.  Here's Mary's comment/sober second thought:

I agree with the parts of the press release you've highlighted, Kishore. I too am excited about the opportunities to shift the focus of health care to the best way to care for people rather than continuing to equate care with visits to a single health professional. The promise of primary care teams with physicians is great. Accessing specialists in a timely way - also great. The promise of no waits for Emergency care concerned me however without us first significantly improving primary care. Without a redesign of primary care, with improvements to coordinating better with specialists, the Emergency wait time targets are unrealistic and may detract us from our focus on getting primary care right.
I absolutely agree.  While the plan looks promising, implementation will be challenge.  Your example is a great one.

Primary care is the bedrock of healthcare, and getting it right will reduce the demand on ERs.  People who are currently using ERs as their default primary care site will have access to a primary care team when they need it.  More people will receive appropriate care for their chronic medical conditions, have fewer acute exacerbations, and therefore have less need to visit the ER.  Primary care redesign will achieve a reduction in ER demand, and thereby contribute to shorter ER wait time.

Attempts to shorten ER wait times without making significant investment in primary care reform may expend unnecessary resources.

But, primary care redesign will take time.   Its effects on ER usage/wait times won't be immediately apparent.  Do we have the patience to let the benefits cascade up through the system?  Which effort makes a better headline?

Cross your fingers, Mary!


  1. Thanks Kishore and Mary. I'm not so sure it needs to take a long time or even a lot of money to improve primary care sufficiently to begin to see some impact on ER utilization. Remember, though, that while non-emergent ER visits are examples of looking after people in the wrong place, the research is clear: they do not clog the ERs and are certainly not responsible for the back-ups in hallways of patients awaiting inpatient beds. The non-emergent cases are triaged and wait hours and hours for treatment.

    To deal with that problem, primary care has to be organized to provide 24/7 service, which suggests larger, more comprehensive clinics and an obligation to recognize that people's health needs don't neatly restrict themselves to office hours. The traditional cottage industry approach to primary care is designed to push people to the ER for want of an alternative, although walk-in clinics in cities decant some of the demand.

    To reduce the number of true emergencies, primary care has to improve its performance in secondary prevention. It is possible to reduce acute asthma episodes to near zero. Improved management of people with multiple chronic conditions, and especially improved prescribing, will also reduce demand. We've talked about this for decades; it is time to combine greatly stepped-up quality improvement efforts with good public policy to accelerate change. The latter requires aligning funding and payment systems with the goals we set.

  2. I don't think they can handle it properly. they need to be really dedicated and look after good maintenance of primary care. thanks for the share dude.
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  3. I am absolutely astonished by the wonderful conversations that regularly occur on this blog. I love that Steven has given such real accounting of what needs to happen in this system. There is so much about this system that if just better utilized, could work wonderfully. And it ties in so perfectly with Kishore's other posts regarding "grassroots" movements/QI. That works on everything. The people who are on the ground might not always be able to see whole picture improvements, but they almost always see ways of improving the system. If you can prevent their practicality from interferring and let their imagination run wild (i always say, if money and time weren't an issue what would you do...) people come up with amazing and innovative ideas that could revolutionize health care. So, congrats Kishore, on starting conversations that lead to ideas, that potentially could lead to change.

  4. Hi Kishore,

    Neat blog. Thanks for cultivating this forum. I wanted to wade into the ER wait times discussion.

    While I think primary care is the foundation of our system, I think it is misleading to think that we can solve ER wait times by increasing access to primary care. Will this divert people? - yes [and only if we are adding good quality primary care]. Regardless ... these patients usually do not take up a huge amount of ER resources to begin with. Rather, we need to address 'access block' in the system as a whole:

    ER wait times come from [our data] 20% of our patients that wait median 13 hours in the ER and occupy stretchers. These are the admitted patients. This is where we need to focus our attention.

    They are waiting because there's no acute care beds upstairs. There are no acute care beds because they are taken up by alternate level care patients. This [as I am sure you know] is the root cause.

    ER waits are the cough [symptom] that reflect what's going on in the system. Access block is the pneumonia. The cure is increasing access to alternate level care [those requiring chronic care, chronic complex care, transition care, respite care and palliative care]. If we can do this - we free up acute care beds.

    More acute care beds available will allow admitted patients from the ER to be decanted - thus allowing us to draw people in from the waiting room.

    Once we're functioning efficiently [6 hour waits for those being admitted] we can focus more on other things like finding ways to manage chronic disease better in the community.

    It would be amazing if Saskatchewan can once-again lead the country in transforming healthcare.

    thanks and keep the good ideas flowing. I know speak for all the ER's when I say that we will keep doing what we've been doing to see people as quickly as possible.

    Nadim Lalani ER physician