Sunday, August 18, 2019

What can we learn from Brampton?

Do we wish to replicate Brampton's disastrous revamped healthcare system in Windsor Essex? 
Windsor Regional Hospital planners like to cite Brampton as an example of what we may anticipate in Windsor if our single site acute care hospital is built.

Yet Brampton's twelve-year old "mega-hospital" is ground zero for some of Ontario's highest hallway healthcare rates. Their acute care hospital and urgent care centre (UCC) are chronically over capacity despite the city's proximity to other GTA-area hospitals. Why do we want to replicate this flawed model?

This is what happened:
In 2007, Brampton replaced its aging downtown hospital with a new facility, Brampton Civic Hospital, nearly 9 km to its north. 
  • Supervisor appointed just 6 weeks after opening: Right after the new hospital opened, Bramptonians raised concerns about excessively long wait times that were leading to health complications and even deaths.
  • Three top executives suddenly resigned: A month after Ken White, the supervisor, started his investigation, he told The Toronto Star to expect more voluntary staff departures, as well as dismissals at all managerial levels over the next couple of months.
  • Massive cost escalations: Ontario's Auditor General subsequently reported that the $614-million hospital cost taxpayers $394-million too much due to cost escalations and the way it was financed via Ontario's preferred P3 model.
Peel Memorial Urgent Care: Is this a gold standard for Windsor-Essex?
...or a UCC cautionary tale?
Ten years later, in response to Brampton's ongoing hospital capacity problems, a brand new $451M UCC opened in 2017 on the downtown site of the original Peel Memorial Hospital. In its first year of operation, it already exceeded its intended capacity:
  • The City of Brampton is now demanding approval for the second phase of the downtown Peel Memorial facility, in order to expand the UCC into a full acute care hospital. Officials are also asking for a third acute care hospital for the community.
  • No provincial government funding approval: In a motion in the Provincial Legislature on October 16, 2018, the request for a new hospital failed to carry. This has left the community stuck with their inadequate UCC and single site hospital.
  • Reduced UCC hours: Effective August 7, 2019, the UCC must register its last patient by 9 p.mThis one hour daily reduction in hours of operation forces more patients seeking medical care to travel to the acute care hospital.
About Brampton's UCC
The only medical care available in downtown Brampton today is for "less serious" conditions. As we discussed in our August 4, 2019 eblast, life-threatening conditions require Emergency Department (ED) treatment. Currently Brampton residents with serious conditions are directed to the ED of Brampton Civic Hospital almost 9 km to the north of where the UCC is located. (Patients do have the option of going to Etobicoke General Hospital instead, 17-28 km east of Brampton, depending on the route taken).

These instructions, on the Brampton UCC's website, couldn't be any clearer:
Emergency Dept. vs. Urgent Care in Brampton
If urgent care was such a good idea in downtown Brampton, why do they now need to expand the facility into a full acute care hospital? Where did their planning go wrong?

Brampton's ten-year old hospital has "aged beyond its years"

Chronic underfunding, a shortage of beds, and a quickly aging hospital are stretching Brampton's health care infrastructure capacity to its limits. "It’s only 10 years old and it’s been seeing volumes that have aged it beyond its years," said Dr. Brendan Carr, President and CEO of the William Osler Health System on Feb. 28, 2018.

How could they possibly have missed the warning signs?
When they began planning their new hospital over two decades ago, Brampton, like other GTA communities, surely were aware they had a rapidly expanding population.

Here in Windsor-Essex, though our total population growth is slower, we need to plan realistically for a known major demographic shift. Our community is rapidly aging.

Did Brampton use the wrong data, or did they overlook reality? What can we learn from their mistakes?
We only have one shot at this!
We need a new plan that gets our future healthcare needs right

One might assume, the last thing Windsor-Essex officials wish to replicate is Brampton's long-term healthcare delivery snafu. We're also quite certain our provincial government is looking for a value-for-money investment.

What we need is a cost-effective solution that provides our aging population with equitable and timely access to appropriate medical treatment.

As residents and taxpayers, we have every right to demand our new single site hospital will be adequate for more than a decade. We can't afford to get it wrong. Let Brampton's healthcare infrastructure miscalculations be a lesson to us.

Fixing mistakes after the fact is always more expensive. If Brampton got its planning so wrong, why are WRH officials using that city's new yet failing healthcare system as an example of what Windsor-Essex residents might expect?

We don't have a backup plan. We'll be paying with our taxes and our lives for generations to come.

In their own words: Weekly round-up
of comments from our friends and neighbours
"We need modern, accessible care near the city centre; we need re-development near the city centre; we need an urban plan that works for the entire region and respects the legacy of the city of Windsor, where most of the population lives and works. This plan is not sustainable, it is destructive and short sighted."
"Keep one in the core and put one in the county. That way the county can pick up 100% of the infrastructure costs of the one outside the city instead of the city being forced to pay 100% for one on the very outskirts."
"Chatham and Wallaceburg both have hospitals with ED's...hell, even Wiarton has one with a population of 2,200 (50,000 during tourist season)"
"Whether you are for this location or against it, the appeal process is a fair and natural part of the process. Let them have their appeal. I would be more upset if we had a group wanting to appeal and being told they can't. It is their right."
"I'm not a fan of the fact that the city is on the hook for all infrastructure costs of a hospital that has to service the entire region."
"Let's stop with the "just build it" nonsense and let's get a proper accounting of all the impacts."
"The new hospital is a long distance from the core of the city."
"How exactly do you justify closing the two existing emergency rooms that are currently accessible to the largest concentration of the poorest and most disadvantaged residents of Windsor Essex County to make a *SLIGHTLY* shorter drive for ONLY SOME members of the county?"
"I'd love to live in the county, but I don't, because I know it wouldn't be practical due to my priorities of needing affordable housing on a transit route, work on a transit route, and easy access to a hospital. Quite frankly, I made my decision of where to live based on my needs, as have the majority of Windsor Essex residents who are vulnerable. That choice: Windsor."
"it's not a mega hospital, they're only calling it that yo get your support."
"Metropolitan REGIONAL Hospital is in the center of the CITY and is very accessible to people needing public transportation. There is ABSOLUTELY no sense putting it on 42."

Sunday, August 11, 2019

A voice of reason or a double standard?

Selective memory and the debatable validity of old data
When just last week, local media turned our July 28, 2019 eblast into a major news story, Janice Dawson, CEO of Erie Shores Healthcare and Leamington mayor Hilda MacDonald quickly rallied to reassure the public that the small community hospital's services are not currently at risk.

On August 7, 2019, in a flurry of Facebook posts, Windsor Regional Hospital (WRH) CEO, David Musyj commented:

"The report this small group relies upon is publicly available - commissioned by the LHIN to focus on many smaller community hospital EDs across the LHIN - written a decade ago in 2009 - has ZERO to do with the new acute hospital located in Windsor to serve the region which was not even discussed until 2012  ...."
A double standard or just selective memory?
It's especially baffling Mr. Musyj implied the 10 year-old HayGroup report is obsolete. If so, why did he endorse 20+ year-old population and economic projections in order to justify the zoning plan for Sandwich South (approved by Windsor City Council one year ago on August 13, 2018)? The data used to greenlight the development of Sandwich South and the County Rd 42 single site hospital plan was based on a 2008 study by EDP Consultants. In EDP's study, the consultants relied on data from the 1996 and 2001 Census and a 2008 report by Lapointe Consultants.

Was it a done deal, long before any public announcements?
Mr. Musyj, in his public responses to our questions about the fate of Erie Shores Healthcare, apparently overlooked a June 2009 Master Plan that identified a new greenfield site and demolition of Windsor Regional Hospital (now called WRH Met Campus) including the 2001 Regional Cancer Centre, as its preferred option.
Healthcare investment is needed in Essex County, beyond Windsor
For those who didn't look past the alarmist local headlines: CAMPP advocates for an alternative regional healthcare system plan; one that includes provincial investment in Essex County, beyond Windsor's boundary. Additional investment in Erie Shores Healthcare could provide more accessible programs and services closer to where rural residents live.

More than a few members of the public noticed the irony - (or "hypocrisy,"  as one commenter put it) - of defending a small community hospital in the centre of Leamington (total pop. 28k) on the one hand, while promoting a plan to remove two accessible acute care hospital campuses from Windsor's (total pop. 217k) most densely populated and established neighbourhoods, leaving the city centre (pop.100k) without hospital-based acute care services.

If implemented as proposed, the current plan will leave half the City's residents with only an urgent care centre (UCC) and outpatient services. This will severely diminish choices to address their healthcare needs. There will no longer be 24/7 services in the heart of the community. No inpatient beds. No ambulatory care. No accessible Emergency Department (ED) treatment for life-threatening conditions or follow-up referrals. 
Map showing Essex County population
Robbing Peter to pay Paul
The Windsor-Essex Hospitals Plan will actually provide rural County residents with a choice of three acute care hospitals depending on where they live: the proposed single site acute care facility on County Road 42, Erie Shores Healthcare in Leamington, and Chatham-Kent Health Alliance, the hospital in Chatham (east of the County line).

Meanwhile, people living in the City of Windsor will be disproportionately disadvantaged with the loss of accessible acute care hospital services, especially those dependent on public transit or living on fixed incomes. Let's not forget the additional infrastrucuture costs that will be carried in perpetuity by city dwellers for this major outward expansion.

It doesn't make sense if making healthcare more accessible to rural residents makes it less accessible to urban residents. We need a better plan.

Measurement by a different yardstick?
2013 HayGroup report (page 139) -- the same report that led to the initial decision to eliminate birthing services in Leamington -- allocated the following scoring to justify keeping Erie Shores' ED services:
ED scoring matrix
Were these same criteria evaluated when deciding to replace Windsor's current acute care hospital campuses with an urgent care centre?

Was 30% of the Windsor scoring devoted to impact on the local community, as it was in Leamington?

There's no indication this was ever done, based on public comments by Bob Renaud, Chair of the site selection committee for the new single site acute care hospital.
According to the January 6, 2016 Windsor Star:
Renaud said the province required the site-selection committee to consider the regional aspect of the facility. He acknowledged the committee did not consider what effect removing two hospitals might have on the city core, however, since that was not one of the criteria his group was asked to assess.
But he said both top locations [The #1-scoring GEM site and the chosen County Road 42 site] would serve a mega-hospital well. “These two sites were really great sites,” he said. “We all felt good about them.”

It was a fatal flaw of the site selection process to not consider the effects on the heart of the City of Windsor. Leamington got it right. Windsor didn't.
Why not create a better, more cost-efficient plan?
We need an improved planning approach to serve our future regional healthcare needs that is based on contemporary demographic and economic data. Given our geographic disparities, with rural residents scattered over an extremely wide area and more than half the regional population living in more densely populated urban neighbourhoods, a one size fits all design isn't in anyone's best interests.

Why not...?
  • Invest in Erie Shores Healthcare by adding to its programs and the number of inpatient beds. This will help anchor the community hospital's ongoing future viability.
  • Add further healthcare supports in the form of one or even two UCCs and/or outpatient services in the bedroom municipalities. 
This approach could reduce the pressure brought by county officials to locate the new single site hospital on Windsor's undeveloped outskirts, in spite of solid environmental, social and financial reasons to build the new facility in an established neighbourhood where the municipal infrastructure already exists.

This will help ensure a cost-efficient solution for current and future Windsor-Essex healthcare needs.

We would hope our elected representatives will bring our ideas to Premier Ford's attention when they meet this month.
In their own words: Weekly round-up
of comments from our friends and neighbours
"It is with some hypocrisy that the Leamington contingent wholeheartedly defends the hospital nestled in its neighborhood while endorsing the overwrought consolidation of healthcare services (mega-hospital) elsewhere to the detriment of everyone else in the county including Windsor... "
"How can a city of 217,000 people lose their emergency rooms to be replaced by urgent care while a town of 27,595 people not be at a similar risk?"
"Come up with a plan that reflects modern urban planning, adheres to ont planning policy and windsor's own planning policy and there would be no lpat appeal. It's your own doing."
"We need modern, accessible care near the city centre; we need re-development near the city centre; we need an urban plan that works for the entire region and respects the legacy of the city of Windsor, where most of the population lives and works. This plan is not sustainable, it is destructive and short sighted."
"It is my hope that the provincial government will give it a well thought out second look. we want to insure what ever tax dollars are spent are wise and lead to improvement not only in health care but to the strengthening of the urban centre which is Windsor. Let us not throw out decades of planning and infrastructure improvements to create a new sprawling development while the centre is let to wither and die."
"Not all of us in the County agree with the chosen location of the Mega hospital. Some of understand the importance of saving our farmland for future generations. Curbing urban sprawl is the mandate of the Province and this location goes against this. Perhaps we need to form a greenbelt coalition before it's to late."
"I'm still waiting for the County municipalities to offer to help pay for the infrastructure and transit improvements that this site will require. It wouldn't make up for what is ultimately a mediocre plan for the entire region (my preference would be to completely renovate Ouellette campus and build a second hospital in the County), but as it stands right now many of the added costs (infrastructure, etc.) will be on city residents who frankly are only getting decreased accessibility."
"Hospital in Leamington should expand and modernize."
"I think it’s fair to say we all want what’s best for our community but have very different ideas about how to get there."
"I thought one reason for a mega hospital was tied into University of Windsor. So why put it so far away students will spend hours travelling back and forth."
"Removing the city’s hospitals and placing one on the fringe, encouraging more sprawl, will be the death knell of Windsor’s heart."
"I’m concerned about the way it’s being railroaded through , telling the public that it’s a done deal."
"It literally only benefits those out in the county and well off people in Windsor who can manage to drive there. It's going to be an absolute mess for other people in Windsor, that's why it's debated so heavily. I'd have to take a bus there or pay for a ride and I'm not looking forward to it."
"We saw a deer on the other side of the road of the proposed Mega yesterday. There is so much brown space in Windsor. It's all politics and we will still be waiting for care while they dig up there and all around it. There is money in this for the wealthy and those that make it happen."
"No one is arguing that this region deserves a new hospital or that patients deserve access to the best healthcare possible. The problem is the proposed location does not make sense from a social, financial, or environmental perspective. Why invest 2 billion dollars knowing that it is not a sound plan. Let’s get this right because the future depends on it!"

Sunday, August 4, 2019

Delay is not your friend

In an emergency, delay is not your friend
Replacing both of Windsor Regional Hospital's acute care
Metropolitan and
 Ouellette Campuses 
with an urban Urgent Care Centre will put lives at risk

It is misleading -- and potentially life-threatening -- to suggest an urban Urgent Care Centre (UCC) is an acceptable replacement for the existing emergency department (ED) in downtown Windsor. Yet, the elimination of both of Windsor's current acute care hospital campuses is what Windsor Regional Hospital (WRH) planners want us to accept as a "done deal," no questions asked.  How is it possible that the location of a new single site acute care hospital -- far from the region's most densely populated neighbourhoods -- is irrelevant from a medical point of view? According to WRH's official Twitter account, apparently the site of a hospital has no impact at all!
WRH comment that the hospital could be built in the Detroit River
Thankfully, the Ministry of Health has been asking the truly relevant questions. Below is an extract from the Stage 1a and b planning documents. Windsor Regional Hospital's responses, in blue, were redacted for reasons that we'll probably never know.

It's critical to inform patients with potentially life-threatening conditions
The distinction between an ED and a UCC is so important that the 2009 HayGroup report we wrote about last week recommends conducting a public information campaign to educate patients about where to go for appropriate treatment. Inadvertently going to the wrong place will cost lives.
Excerpt from HayGroup report to LHIN 2009
Excerpt from HayGroup report to Erie St. Clair LHIN, 2009

Yet in Windsor-Essex,
the single site hospital proponents use misleading language
(like calling the UCC - - a satellite ED)
to blur the critical distinctions
between these two types of facilities!


Knowing when Urgent Care is the right treatment
A UCC is not intended for emergencies. This is what patients are advised to do, on the Hamilton Health Sciences website:
When lives are at risk, delay is definitely not a friend
For patients with potentially serious conditions, minutes matter. It's critical to know where to go for the right treatment. But how do you know?
  • Do I have indigestion or am I having a heart attack?
  • Is it a simple broken bone or a more serious compound fracture?
If you don't have a car, or you don't have money for a taxi or an ambulance, an inaccessible hospital poses a life and limb threatening risk.

A UCC has no ICU or overnight beds
This week Windsor Regional Hospital's CEO tweeted:
Tweet about ER physicians at the UCC
UCCs are typically staffed with ER physicians and nurses. But that's not the issue. Without an attached ICU or overnight beds, patients with life-threatening conditions will have to travel to the proposed acute care hospital location on County Road 42 for the treatment they need.
Tweet that 90% of patients are not admitted
We also don't challenge the assertion that the vast majority of ED patients go home without being admitted as inpatients. Again, that's not the issue.

How many patients are sent home with follow-up referrals? 

The HayGroup report was concerned about where referrals might be located. They described "referral centres" that are "in the city, but not on the outskirts": Typically referral centres are located at or near acute care hospitals.

Moving all hospital healthcare to Windsor's outskirts means the referral centres will no longer be located "in the city." How many additional trips will patients have to make in order to complete their treatment?

What about those who DO need to be admitted to hospital? 
There are inpatient transfers between Ouellette and Met Campuses today -- a distance that's just under 4 km. The distance  between the proposed UCC and the new hospital site is 15 km. The new hospital's proponents haven't provided the public with any data comparison of:
  • How much of the transfer cost (time and money) will be offloaded to patients?
  • What if you don't have a car or somebody to drive you?
  • What is the financial impact to taxpayers for ambulance transfers?
The planning documents submitted to the Ministry of Health contain some insights into these unanswered questions.

1.  Nearly one in three patients needs treatment at an acute care hospital
The second largest group of total ED users have what is known as emergent conditions. Their triage level is classified as CTAS 2 on the 5-level scale used to prioritize the seriousness of patients' conditions. This patient group needs treatment in an acute care hospital.
2. More than one in three ED patients live in the densely populated and centrally-located neighbourhoods near Windsor's existing hospitals. 
The table below shows where Windsor Regional Hospital's ED patients live: 71% are in the City of Windsor. (It appears many of Essex County's 181k residents seek emergency treatment at Erie Shores Healthcare in Leamington or Chatham-Kent Health Alliance in Chatham rather than travelling to Windsor.)
On average, 37% of total ED visits are by people living between East Walkerville and Olde Sandwich Towne (Windsor Wards 2, 3, 4 and 5) -- which includes the region's most densely populated neighbourhoods. All have excellent access to one (or both) of Windsor's two acute care hospital campuses today. The distance to the proposed acute care hospital site from each of these neighbourhoods ranges from 11 km to 18 km.

Do the math: More than 13,000 patients a year who live in Windsor's central neighbourhoods need treatment at an ED (37% of 35,856 CTAS 2 patients). For them (and their families), the travel distance will exponentially increase.
Population density graphic
Source: Stats Canada 2016 Census data
3. One in 6 patients visits the ED overnight
We saw from the response to the Ministry's questions that the proposed UCC will close its doors to patients at 10 p.m.
Do the math: With 16.6% of ED visits being made overnight, 8,000 patients (37% of 21,733 annual visits) who live in Windsor's central neighbourhoods will be most negatively affected. They will be forced to travel to the proposed exurb hospital if they need treatment after the UCC closes its doors.


Shifting the blame for an inadequate plan
Instead of addressing the many flaws that seem to be preventing the hospital planning process from progressing more rapidly, Windsor Regional Hospital's CEO David Musyj prefers to insinuate that CAMPP's appeal has caused a delay. On July 30, 2019, he even suggested we drop our LPAT challenge. Why would he not want this important and transparent provincial oversight process to run its course?
David Musyj tweet to drop the LPAT
On April 16, 2019, the LPAT Tribunal granted CAMPP an appeal "based on the breadth and nature of the likely issues." Since 2015, Mr. Musyj has insisted that Windsor-Essex residents accept the County Road 42 acute care hospital site as a "done deal." Yet, if implemented as proposed, the location will create unacceptable life-threatening delays for many thousands of people.
The ultimate delay: If we don't get the plan right, the region will be stuck with an inadequate single site acute care hospital location for generations to come.

Locating our new regional hospital in a neighbourhood where exponentially more people already live will save lives. Why not build a UCC in a county municipality (or on Windsor's outskirts) where both population and population density are signficantly lower than in the heart of the city?
Stay Tuned
Later this month: How are similar issues affecting another
Canadian community grappling with the same problems?
In their own words: Weekly round-up
of comments from our friends and neighbours
"I can’t speak for everyone but i still truly believe that dialogue and discussion is the only way to resolve our differences. If we could come to the table and find common ground we could probably develop a plan that satisfies all interests."
"Really concerned about lack of support from elected people that should be stepping  up."
"The  money spent on lawyers shows a lack of respect for taxpayers suffering from long term lack of  funding in this area. The  money is intended for health services, not to help a small group of people assert their will. "
"The evidence is so overwhelming it is baffling."
"There are many more concerns that I have in addition to the location. These concerns have been expressed a number of times, but David Musyj just wants to completely ignore them without so much as an understandable explanation on why he's ignoring them."
"Reading between the lines I'm wondering if the province is suggesting the current plan does not meet "the service needs of the region" or is not guided by "sound fiscal planning""
"We live in a democratic society where people, groups, and organizations are allowed to express their opinions and positions freely. No one should be afraid to advocate for their members best interest. There should be zero tolerance for bullying."
"Thank you Tim for saying it exactly as most of us feel. We have to remember that people usually act this way (bullying) when they feel they are being 'found out' (for lack of a better word), feel they have no other way to go, or their ego needs a boost and can get it no other way because we are not playing into their whims."

    -- in reference to Tim Stewart's letter published in the Windsor Star on July 27, 2019: https://windsorstar.com/opinion/letters/reader-letter-mayor-should-not-bully-organizations-about-mega-hospital-site