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Five Ways to Fix Emergency Care in BC

Strengthening primary care, mental health supports and transport could improve health in and out of hospitals, report UBC med students.

Michelle Gamage 25 Mar 2024The Tyee

Michelle Gamage is The Tyee’s health reporter. This reporting beat is made possible by the Local Journalism Initiative.

Medical students at the University of British Columbia have come up with five recommendations to improve emergency departments across the province.

The recommendations form part of a report put together by the Medical Undergraduate Society’s political advocacy committee in the faculty of medicine, which gets a chance once a year to sit down with MLAs and dive into the most pressing topic of the day.

This year 46 political advisory committee members presented Premier David Eby and Health Minister Adrian Dix with "Enough Waiting: A Call to Resuscitate B.C. Emergency Departments," which explores the stresses impacting emergency departments across the province and suggests ways to alleviate pressures.

Emergency rooms aren’t doing so hot. As the report notes, there’s understaffing, abuse of staff and a lack of available beds.

“We need a fundamental shift in the way we think about health care in B.C. and in Canada,” Sebastian Lopez told The Tyee. The second-year medical student and political advisory committee senior chairperson was one of the four lead authors of the report. “We need to invest in people’s health outside of the emergency department to help with issues inside the emergency department.”

The report’s five recommendations seem relatively straightforward on paper: expand primary care, invest in community health supports like mental health and long-term care facilities, improve hospital flow efficiency, increase transportation options in rural B.C., and collect data to create evidence-based improvements.

In practice, they’re a little more complex. Let’s dive in.

1. Expand primary care

Currently many patients go to an emergency department because they don’t have any other way to access the health care they need in a timely way, said Kathryn Haegedorn, a third-year medical student at UBC and another lead author for the report.

“This is not a problem of people inappropriately accessing the ER. This is a problem about access period,” Haegedorn said. Many communities in B.C. don’t have walk-in clinics and family doctors rarely set aside blocks of time reserved for walk-in or urgent patient care, she said. If someone doesn’t have a family doctor or can’t see them for several weeks, their only option is an emergency department.

So the fix is simple: to reduce the strain on emergency departments, B.C. needs to bolster its primary care services.

Urgent and primary care centres are not a silver bullet because they provide fragmented patient care, she said.

For clarity: a family doctor or nurse practitioner provides primary care as the single person who oversees your health over a long period.

A walk-in clinic offers primary care but a patient might see a different clinician every time, who will refer to their general health-care file.

An urgent and primary care centre is for critical but non-life threatening illnesses or injuries, such as stitches, high fever, a lung infection, or needing an x-ray for a sprain.

Emergency departments are for critical or life-threatening conditions or mental health emergencies. Being in a car crash, having trouble breathing or catching your breath, having signs of a stroke, uncontrolled bleeding, being at risk of serious self-harm, believing things that are not true or unable to care for oneself such as not eating are reasons to seek emergency care.

One solution could be to create financial incentives for family doctors to work outside regular business hours and to reserve space for urgent care, Haegedorn said.

Another solution the province is already working on is building out the 811 health-care hotline so patients can call in and be assessed in a timely fashion by a nurse and a physician if needed.

2. Invest in community health supports

The second recommendation focuses on preventative health, which is something medical students are taught in school but don’t see prioritized in the health-care industry, Haegedorn said.

To do this B.C. should expand its Medical Services Plan to cover a broader range of mental health appointments and build out its long-term care facilities.

“If you want mental health support and have to pay out of pocket that’s a huge barrier to accessing care,” Haegedorn said. Having a regular mental health worker can mean people get care before they’re in an emergency.

Seniors make up around 30 per cent of all patients visiting the emergency department, Haegedorn said. This is concerning because emergency departments can’t offer continuous care and seniors tend to have complicated health issues that are best addressed by a family doctor.

3. Improve hospital flow efficiency

To improve hospital flow, the report recommends building more beds and changing how we fund hospitals.

Often when patients visit the ER they get “docked” there because there isn’t a hospital bed they can be admitted to. Haegedorn said to address this problem B.C. needs to build and staff more hospitals in underserved communities and to change its funding model in busier urban centres.

Health care in B.C. is currently funded through a "global budget" model where a health authority gets an annual fixed chunk of money and then distributes the funding in lump sum payments to facilities and services.

A better way to fund health care is an “activity-based funding" model, which allocates funding throughout the year based on how many patients a doctor sees. This could boost competition and efficiency between hospitals in the Lower Mainland but is not recommended for rural hospitals, Haegedorn said.

In 2010 B.C. tried out activity-based funding in a pilot project which didn’t change the quality of care but decreased the volume of medical cases and increased the length of stay for patients, according to a 2010 study.

Investing in housing would also help free up beds, Haegedorn said. Some patients who would otherwise be ready to discharge are experiencing homelessness, or lost their home during their stay in hospital and don’t have a place they can be safely discharged to, she said.

Programs in Ontario and Alberta provide temporary housing for unhoused patients so they can recover and get back on their feet.

4. Increase transportation options in rural BC

The fourth recommendation focuses on improving rural transport.

Data from 2019 shows the average life expectancy of females in B.C. is 86.4 years, but for females living in northern B.C. that drops to 81.9 years, Haegedorn said.

The whole northern half of the province doesn’t have close access to cardiac care and needs to be flown to Kelowna or Vancouver in the event of a heart attack or stroke, Haegedorn said. “We know delayed treatment means worse health outcomes.”

A woman in her twenties with light-coloured skin and shoulder-length brown hair wears a sleeveless red dress with embroidered beads. There is a stethoscope around her neck.
Currently, many patients go to an emergency department because they don’t have any other way to access the health care they need in a timely way, said Kathryn Haegedorn, a third-year medical student at UBC and another lead author for the report. Photo submitted.

While a cardiac care unit is under construction in Prince George, more needs to be done to serve remote communities, she said. This doesn’t mean building a hospital in every community, but it could mean bolstering the province’s air ambulance fleet and infrastructure for air ambulances to land so communities can readily access emergency transport when needed.

Patients in rural communities also need more financial support for when they have to leave their community to access care. The average patient will pay $2,000 out of pocket per condition for things like gas, meals and a place to stay when they visit Kelowna or Vancouver for care, Haegedorn said.

In an emergency a patient can get flown to an urban centre for care and then “get stuck” because they can’t afford to fly home and there isn’t a Greyhound or provincial public transit system they can use, she adds.

“These are barriers for people who can’t pay and it contributes to inequities of those living in rural B.C. who have to pay more but can’t get the same quality of treatment,” she said.

The province’s Travel Assistance Program is supposed to help with the cost of leaving home for medical care but it doesn’t cover food, accommodation, gas or local transit fees. Further, the program can be burdensome for seniors who are less technologically inclined, Haegedorn said.

5. Collect data to create evidence-based improvements

Finally, the report calls for using data to improve the health-care industry.

“We don’t do a great job of this in B.C.,” Haegedorn said.

As an example, she points to how the aging population and physician shortage has been part of B.C.’s zeitgeist for years, but from 2014 to 2023 UBC didn’t add any seats to its medical school, which was the only medical school in the province.

In 2023 it added 40 seats, but it’s at minimum six years before those students are doctors, she said, adding B.C. is similarly “playing catch up” with its number of trained mental health staff and counsellors.

A sign in the foreground reads ‘Delta Hospital. Fraser Health. Emergency.’ In the background, an ambulance is parked in front of a one-story tan brick building with a red ‘Emergency’ sign.
To reduce the strain on emergency departments, BC needs to bolster its primary care services, the UBC report says. Photo for The Tyee by Michelle Gamage.

B.C. could benefit with a redistribution of services, she said. From 2007-08 to 2017-18, Northern Health had the highest rate of emergency department visits per 1,000 people for mental health and substance use issues, while Vancouver Coastal Health had the highest number of specialists per 1,000 patients to treat those issues but the lowest demand for those services.

Medical students get into this field because they want to help people, Lopez said. “But we don’t want to work within a system that can’t meet the needs of all of the patients we got into medical school to serve.”

At the heart of the report is a desire to improve patient care which has the downstream effect of improving his future workplace, he added.

Lopez said the report was well received by the BC NDP, BC United and BC Green parties.

The Tyee contacted the Ministry of Health to ask if it would adopt the report’s recommendations. In response the ministry pointed to a recording of a March 10 press conference where David Eby was asked about the report. Eby said family physicians have an obligation to provide after-hours care and that B.C. recently added 700 new family physicians who can provide after-hours virtual care.

B.C. is also opening new urgent and primary care centres across the province.

“We’re discouraging family doctors from operating the whole model of drop-in clinics where you don’t have a relationship with the doctor,” he said, adding long-term relationships between doctors and patients is the goal.  [Tyee]

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