As the current discussion in Muskoka demonstrates, few things evoke emotional reactions more than hospital planning. Access to a convenient hospital has the potential to be a life or death factor for all of us, every day of our lives from the first day to the last day. But hospital planning is complicated and is fraught with (to borrow a phrase from Al Gore’s book) several inconvenient truths (ITs).
IT #1 – “The government” pays for health care. “The government” is us.
IT#2 – There are not enough dollars to meet the needs of Ontario’s 250 hospitals all at once. The Ministry of Health has the task of managing the queue of projects for new hospitals and upgrades. It is generally more productive to approve proposals from people who understand their need and have a reasonable plan to address it. That is why MAHC is looking ahead and working with the Ministry early.
IT #3 – The Ministry of Health follows a proven process for project management. The Ministry uses a five-stage process, but for simplicity I will describe it as a three-stage process. Stage 1 is the Concept Stage in which all stake-holders (including the public) explore, debate, and agree on the optimum concept. That is critical to avoid wasted time and money for changes in later stages. Stage 2 is the detailed development stage in which detailed plans, drawings and specifications are made, cost reduction strategies are explored, and the final plan is tendered for competitive quotes. Stage 3 is the actual construction. After a number of starts, MAHC is still in Stage 1. Three concepts are under consideration.
IT #4 – Every project is unique. The size and shape and spacing of population centers in the catchment areas of Muskoka hospitals are unique. Solutions that work in other areas may not work here.
IT #5 – Free land is not free. If one town offers land that could be sold to another party for revenue, it is a cost to the town (to us). It is not free and must be included in the cost equation.
IT #6 – In the concept phase, it is critical to consider societal costs and not just bricks and mortar. For example, MAHC is planning to follow the Ministry standard that now calls for 80 per cent private rooms in order to prevent the spread of today’s virulent infections, because prevention is cheaper than cure. Similarly, inconvenient access often results in people avoiding a visit until a condition becomes more severe and more costly to treat. Inconvenience and excessive travel time can result in disability or even death.
IT # 7 – The single-site model does not meet the needs of the entire population in the catchment area. The single-site model would build a brand new hospital. It could be located in Bracebridge, or Huntsville, or in the geographic center of the huge catchment area. Total cost would be about $350 million with some variations for land and services. On the surface, the single-site option appears to offer savings to the government (which is us), but the inherent inconvenience of a single-site hospital in Muskoka’s unique geography would be more costly to society when personal time and travel costs (and emissions) for patients, medical staff, paramedics, volunteers critical to hospital staffing, and visitors are considered. A return trip from Burk’s Falls to Bracebridge would take two hours. A return trip from Bala to Huntsville would take two hours. Both trips could take longer in winter. A single-site hospital in the geographic center would equally disadvantage all current residents and related businesses. Over time, that would also impact health outcomes as well as area growth patterns and infrastructure planning.
IT #8 – The “Centers of Focus” model would result in increased operating cost, eventual loss of core services, and difficulty attracting and retaining physicians who value the doctor-patient relationship. The “Centers of Focus” model would have a combination of new space and renovations at both sites with acute care at one site and ambulatory care at the other. Huntsville could be the acute care site and Bracebridge could be the ambulatory care site, or vice versa. MAHC estimates indicate costs would range from $374 to $408 million. This option has the same travel cost and risk concerns as the single-site option.
Respected local physicians say acute and ambulatory services are linked together and without on-site surgical services, there would be an eventual loss of all core services at the ambulatory site. Also, this model inherently leads to hospital doctors working separately from clinic doctors thereby diminishing the doctor-patient relationship. In her book Better Now, renowned professor Dr. Danielle Martin says a weak doctor-patient relationship results in costly over-testing and over-treatment.
IT #9 – The two-site model is consistent with Ministry specifications for small hospitals and is the only model that can meet the needs of all taxpayers in the entire catchment area. The two-site model would continue to provide acute care and specific specialities at both sites in a combination of new and renovated buildings. The MAHC estimate for this model is $475 million. Municipal leaders like the concept but are rightly concerned about the impact of the $114 million local share on municipal debt.
IT #10 – The current uncertainty about the future of our hospitals is a silent threat to local economic development. Many are looking to escape the big cities and the GTA needs relief from rapid growth. Businesses and retirees bring money and jobs. It is a well-known fact that the presence of a good convenient hospital is often a prime consideration for retaining and attracting businesses, talented employees, and retirees.
IT #11 – MAHC must be challenged to come up with a more economical version of the two acute-site model. There are reasons to believe that a modified and less costly two acute-site project could be done. Cost estimates in the public media may contain some different components, but a comparison with recent hospital projects in Canada, the USA and the UK indicates $1 to $2.5 million per bed vs $4 million per bed for the MAHC model. A lower cost per bed could reduce the cost of the preferred option from $475 to under $242 million, and reduce the local municipal share from $114 million to $58 million.
Hugh Holland is a retired engineering and manufacturing executive now living in Huntsville, Ontario.
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