Tuesday, October 4, 2016

Why Health Care Is Not Safe With Bureaucrats

My final "freebie" memoir excerpt, and salient to Ontario's misguided Patients First plan. The names have been changed, but yes, this is a true story:

It would be one thing if we acted like the downtrodden dregs of society simply weren't there, whitewashing how the lesser half live. Then helping the poor, the frail, and the disabled - housing, feeding, clothing them - would be an act of charity...God's work for people of faith. But we don't. We set up bureaucracies, and staff them with people whose job security is measured not by what service they provide, nor how satisfied the clients are, but by how much of the budget can be preserved. Then we pit one set of bureaucrats against the other, to piss away hours on end haggling over the same pot of funds. It's the most perverse way to structure social services, and betrays the very clients the system is purportedly designed to serve.


"I want to thank you all for coming here today - Dorothy, your daughter Cathy, Dr. Warsh, the Community Health Centre nurses - and of course my own staff from Community Care. I'd like to open this meeting by looking at the broader context under which we're providing home care services to the local community. Over the next twenty, years, the number of Canadians over the age of sixty-five is going to grow dramatically. Given the aging of the population, and the ongoing struggles of the broader economy, the province is facing enormous budgetary pressures to meet the health care needs of--"

I was putting a stop to this before it went any further. "I'm sorry to interrupt," I said, "but I've been listening to this kind of boilerplate since I started medical school almost twenty years ago. We are not here to discuss Community Care's ten-year budget forecast and strategic plan. We are here to discuss the needs of one client that your organization is not meeting, despite the very recommendations of your own staff."

Dorothy was in her early 70s. She had cognitive problems, but was competent to handle finances and her other affairs. She used a walker without protest, but sciatica and worn out discs in her spine made it difficult for her to bathe and do housework. Dorothy was also the stubbornly devoted caregiver of her husband Charles, who had advanced but non-progressing dementia. Her grit reminded me of my own late grandmother. Just like my Nana, Dorothy was no fool.

Dorothy was receiving home care once or twice a week to help her bathe, but the service was stopped just over a month earlier without warning or explanation. The Community Care office had already conducted two separate assessments of Dorothy's capacity for self-care, and both assessments reported she couldn't bathe independently. Nevertheless, the service was still stopped.

After a short time without regular baths, Dorothy developed an angry, infected rash on her back. She responded well to antibiotics and daily dressings by our CHC nurses, but she never should have had that rash in the first place. After weeks of unreturned phone calls, delays, and complaints to higher executives at Community Care, we were finally able to arrange this meeting to sort out what the hell was going on.

It took all of five seconds before Thing One - the jargon-spewing middle manager from Community Care - raised my ire.

"I appreciate your point of view, Doctor," said Thing One, "but if I could, I'd just like to explain Community Care's new model going forward. We're making a paradigm shift, away from direct service provision and towards teaching and empowering the client to help themselves."

"That's all well and good," I said, "but I repeat: your own assessments, by your occupational therapists, say Dorothy can't bathe herself. It doesn't matter what 'paradigm shift' is going on. Dorothy is not physically capable. She needs the service. What's the holdup?"

"According to the criteria we use to evaluate service needs, Dorothy is a good candidate for facilitative training."

"Then your evaluation criteria need to be re-examined." Along with your head, I thought, if it can be dislodged from your backside. "I don't see how this could be more straightforward. She needs the service. You have documented proof she can't physically do it on her own. Denying her the service has now caused clinical complications resulting in an ER visit, multiple medications, and daily visits to the CHC. The whole point of home care is to prevent these things from happening. How much does a support worker cost per hour? How many baths could Dorothy have had for the money spent on her health care in the past month? How many baths could she have for the money spent to have this meeting? I'm pretty sure that my sitting here costs more to the taxpayer than giving Dorothy a weekly bath for months."

"It sounds as though there's a disconnect between our needs assessment and what Occupational Therapy has indicated. That's something we need to revisit."

Cathy, Dorothy's daughter, interjected before I blew my top. "Stop. Just stop. I'm going to tell you what I witnessed when Dorothy tried to shower. This is a proud woman - do you think she likes having someone else bathe her? Only once a week? She cannot lift her leg to step in the tub. She simply can't. She cannot clean her back that's covered in boils." Both Cathy and Dorothy fought back tears. "I had to personally help her undress, lift her legs into the tub, and wash her like she was my child. 

"I'm self-employed, and live almost an hour away. I gave up a day of work to drive for this meeting. It's luck - luck! - that I came early enough to see what she actually goes through, and to help her because you won't."

Thing Two, Thing One's overseer, chimed in. "We'll reinstate the support worker for baths. We can have that in place next week. We'll reassess Dorothy's needs sometime after that." She glared at Thing One. "And we'll put the brakes on the new Client Needs Tool until we get more client feedback." 

In an ideal world Thing One would fall on her sword somehow, perhaps demoted or simply let go. She made the wrong call, putting meaningless paper guidelines ahead of the client in front of her face. 

More likely, she'll get a raise.

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