Charlotte Gray is a CMAJ contributing editor.
Canadian Medical Association Journal 1995; 153: 1789-1790
You can't spend much time in Toronto these days without realizing that it is a battleground. This being Canada, the weapons are restricted to lawn signs, huge posters, newspapers columns and editorials, and fierce arguments at the water cooler. Still, the proposal to close about 25% of the hospitals in Metropolitan Toronto, and cut 2800 jobs in the process, has galvanized this metropolis in a way few other issues could.
Politicians and health care planners in cities that have already started restructuring their hospital sectors -- Calgary, Halifax, Montreal and Vancouver are examples -- might be forgiven for raising a sceptical eyebrow at the furore, for they already know that such cuts always trigger outrage. They also know that hospital cuts in Canada's largest city are way overdue.
Although Ontario has pruned the number of hospital beds by 20% over the past 5 years, it scarcely touched the bricks and mortar of the hospitals themselves. During the New Democrats' 5-year regime, it would have been more than Premier Bob Rae's political life was worth to chop jobs in the hospital sector, where 61% of employees belong to unions. And Conservative Premier Mike Harris, mindful of the electorate's love affair with medicare, steered well clear of any talk about health care cuts during the 1995 provincial election.
During that campaign, he specifically promised that his government would not cut the province's $17.4-billion health care budget, which accounts for about one-third of all provincial spending. Now that he is premier he faces a provincial deficit of $9 billion and impending cuts in transfer payments from Ottawa. No wonder he is taking a serious look at a report that would see $1.3 billion in spending cut from Toronto-area health care facilities in the 5 years it would take to implement the plan.
But if observers outside Ontario are muttering "it's about time," health care providers within the province are watching nervously. The Toronto report, Directions for change: toward a coordinated hospital system for Metro Toronto, is one of many such examinations under way in Toronto. Communities like Ottawa want to know how sharp the Harris axe will be -- and whether community protests will blunt it -- before embarking on their own hospital reorganizations.
The 239-page report was issued in September by the Metro Toronto District Health Council. It was commissioned by the Rae government and took 2 years and $5 million to complete. The provincial government is expected to respond early in 1996.
The authors say the term "hospital system" is an oxymoron when applied to the city's hospitals. "Each hospital currently operates independently with respect to planning, setting priorities and delivering services," points out Edward Crawford, chair of the Canada Life Assurance Committee and chair of the committee that produced the report.
In effect, this means that Toronto's hospitals compete for scarce resources in Darwinian fashion, with victory resulting more often because of sharp elbows, not proven need. There is duplication in administration and support services. In 1994, the 44 hospitals in Metro Toronto cost $3 billion to operate; 25% to 30% of that money, depending on the hospital, went to administrative, overhead and infrastructure costs.
The committee has therefore tried to create a "big picture" of Toronto's hospital services. It predicts a shift away from acute care provided in inner-city buildings and toward ambulatory care provided in the suburbs. The shift would include:
All the proposals reflect current thinking in health care policy -- similar proposals have recently been implemented with great success in Melbourne, Australia. However, when the debate gets down to naming hospitals scheduled for closure, the fights begin. Some of the suggested closures include the Western Division of the Toronto Hospital and the Wellesley and Salvation Army Toronto Grace hospitals. Several mergers are also suggested -- one would see Women's College Hospital integrated with the Sunnybrook Health Science Centre.
As soon as the report was published, hospitals scheduled to disappear started churning out press releases, vowing to fight for survival. If he decides to accept the report's recommendations, the biggest fight facing Health Minister Jim Wilson will come from supporters of the 220-bed Women's College Hospital, where 50% of the medical staff are women. Toronto Star columnist Michele Landsberg trashed the report for treating hospitals like dots on a map. "The authors did not stop to consider that Women's College Hospital now runs in the black, is highly cost effective, is a leader in obstetrics, and is not a dot but a breathing institution with a deeply loyal constituency."
The hospital fought, and won, a bitter battle for survival 6 years ago, and Landsberg said its name came up again because "they weren't thinking about humans, only about numbers, [and] because they didn't think about women as a special medical clientele, or even admit that women's health interests aren't always well served in male-dominated institutions."
Her passionate defence of the hospital is bound to give politicians goosebumps, simply because the fact that her arguments don't begin to address the wider pressures facing planners is irrelevant. Women's College can call upon a huge army of supporters that includes Dr. Bette Stephenson, a CMA past president, a member of the hospital board and a past minister of health in a Tory government. The hospital lobby comprises people who are expert in marshalling support for causes and reaching the ears of the powerful. Will the Harris government be able to stand its ground before Toronto's feminist establishment?
Jim Wilson has not committed himself to full implementation of the Toronto report -- he has simply said that the government is willing to close hospitals if this would eliminate "duplication, waste and administrative inefficiencies."
But if the government allows Women's College to survive, what sort of message will it be sending to other Ontario cities, where closures are also bound to be proposed?
In the end, the battle over closures will likely obscure another important recommendation: the provision of alternative forms of care in the community. The report called for $75 million in annual spending to improve community-based services, such as visiting nurses and 24-hour clinics.
Toronto physicians are concerned that the Harris government may be tempted to use the savings from hospital cuts to pay for its promised tax cut, and not to reinvest in the health care system. For instance, when the city of Windsor asked for $68 million to help downsize its hospital sector, Wilson's first reaction was to balk at the cost.
Some Ontario hospitals have already reacted in response to what they predict will be massive cuts in hospital spending. In September, the University and Victoria hospitals in London announced they would create Canada's second-largest teaching hospital by merging -- and in the process would save $40 million annually by reducing duplication, particularly on the administrative side.
Whatever the government does, it knows there will be opposition. At its November convention, the Ontario Hospital Association released a survey showing that most Ontarians oppose any health care cuts. Only 10% of respondents in the Environics survey thought there were too many hospitals in their region.
However, it is also true that the longer Mike Harris and his government wait, the more difficult hospital closures will be. Keep this in mind: whatever happens to Toronto hospitals early in 1996 will set the pattern for the rest of the province to the turn of the century.