Hospital: A Detailed Argument

John Sewell speech,  Sunday, April 10, 2016, 2 pm

Simcoe Street Theatre

 

1. The general policy the provincial govt seems to follow is this:

Build a new hospital on the edge of the community, then demolish the old hospital.

This has happened in North Bay, Peterborough, Owen Sound, St. Catharines., Barrie, Coburg and Port Hope, Woodstock

 

2. Why that policy is wrong:

a) Patients and staff are inconvenienced with longer more costly travel to the edge of the community. Any location is good for an ambulance – traffic is rarely a consideration since people move out of the way of a siren. Patients and staff are a different matter. For both – almost 1000 employees doctors and volunteers work at the Collingwood hospital – connections are usually best in the centre of the community. Getting to the centre of the community is usually the shortest trip for most people. Taxis are most available in the centre, and again central trips are shorter so the cost is less. 89 per cent of those who use our hospital come from Collingwood and its immediate surrounds.

And there are lots of trips to and from the hospital. In Collingwood, there are eighteen  trips a day for dialysis patients, ten trips a day for chemotherapy patients, 10 trips for mammograms, 15 trips a day for patients entering surgery, 30 trips a day for ultrasounds. Putting a new hospital far outside each community will impose significant travel burdens on most of these patients, their friends and family.

b) It puts the hospital a long way from doctors’ offices and forces them to consider moving. Many such offices are right nearby – including the medical centre immediately north of the hospital.

c) It is often a long way from retirement homes which have much traffic with hospitals.

Several such homes are very close to the hospital – Sunset Manor, Raglan Village.

d) It is contrary to provincial planning policy which urges intensification, not sprawl. Provincial Planning Policy – municipalities must act in a manner that is consistent with it.

e) It wastes an existing facility and dooms it to demolition

f) It severely impacts the economic viability of the central area of the community since it takes so many people staff and visitors – away from central area amenities such as shops and restaurants. I am not able to quantify the economic impact of large institutions such as hospitals in the centre of the community. An economist friend told me he did not know of any such studies. But one can imagine how the economic impact works. A doctor who has been working long hours decides a bunch of flowers for his or her spouse would be appropriate, and stops at a local store to pick them up.

Several cleaners decide they should have a coffee or a drink after work and drop into a local establishment for an hour. They might stay for dinner. It’s raining – maybe I should pick up an umbrella or a better raincoat at the shop down the street. When there is a staff of 700, the economic impact of just 5 per cent of these people stopping locally to purchase something is enormous.

g) Building new on the outskirts is very costly. Renovating and adding to the existing facilities is usually one third or less of the cost of a new hospital, according to data from Infrastructure Ontario..

h) It assumes that money spent on bricks and mortar will improve health care, when it is usually staff that improves health care.

i) Hospital foundations have trouble raising their 10 per cent of the capital cost of a new hospital, particularly after donors have been encouraged to give for renovations to the old hospital which will be demolished.

j) Municipalities often must pay the costs of new water and sewage services and roads, probably in the tens of millions of dollars you pay for in property taxes.

I just gave you ten reasons why the idea of locating a new health facility on the edge of a community is wrong-headed. But that is government policy.

 

3. A significant problem with hospitals in smaller centres is the funding policy: the policy has been to flat line budgets, but in smaller facilities that quickly means a reduction in services. The annual budget of the Collingwood Hospital is $55 million, which doesn’t allow much room for wiggling. Another three or four million dollars a year would go a long way to improving health care.

However, it seems to be the policy of the provincial government to locate new hospitals on the edge of communities rather than in the central area. That is now being proposed for Windsor – out past the airport and demolish the two large hospitals in the centre of the city – and Bracebridge/Huntsville where the proposal is to put the new facility half way between the towns, and demolish the hospitals in each town.

 

4. Will that happen here in Collingwood? Let’s look at the situation here. 

First, a short history of the hospital

Women were never treated as equals in the 19th century – they were denied the vote, they had limited property rights and they held little social status. But many women found very positive outlets for their desire to be treated as equals. They embarked on public missions of their own to remake society in areas that men seemed to have little concern for. One example of the expression of these values in Collingwood was the establishment of the town’s hospital, an enormous advance for the population.

Liza Letta, wife of the rector of All Saints Anglican Church, began meeting with several of her friends in the mid-1880s to establish a place where sick people could be cared for. This was not something men much cared about – it was women’s work. She created a group of several dozen women who conceived of the idea of a hospital, and she herself pledged money towards its operation.  Simcoe County Council was approached for a donation in 1885, but rejected the idea – no hospital existed in the county at that time, and the men sitting on County Council probably felt it was an unneeded frill.  Similar requests were dismissed in 1886 and 1887, but finally in 1888 County Council advanced a grant of $500.00.  On October 24, 1889, the eight-bed facility opened for residents and for sailors.  It was governed by a board of directors of 24 – all women.  In the first year, 38 patients were admitted and discharged.

The major funding came from local donations, although County Council agreed in 1891 to provide a continuing annual grant of $140.00.  The hospital – now called the General and Marine Hospital – expanded to serve the community.  In 1907 a dietician was hired on staff, reflecting the important principle that public health measures have far more impact on good health than simply treating disease.  In 1913 the Ann Long Nurses’ Home was added to provide residence and training for nurses.

What a powerful institution it is that women created here. We own them a great debt of gratitude. I might say they went on to create the Collingwood Children’s Aid Society, and women were prominent in the activities of the society, which concerned itself with homeless children and the general poor treatment of children.

 

5. Does the current hospital facility need replacing?? The preparatory report prepared for the hospital board and submitted to the government – called the Pre-Capital submission – argues it should be replaced. That report says the current hospital, and I quote, “cannot be renovated for future use.” Done. Tear it down and move on.

Often there is an assumption that new big facilities are more efficient, that doctors nurses, and other health professional only want to locate in large centres with the latest and most sophisticated equipment, or that the best care is the most technological in nature.

It is clear that new facilities can reduce infections: infections in St. Catharines are down 50 per cent with the new hospital. But appropriate renovations to old facilities can produce the same results.

The study for our hospital was done by Stantec Consulting. It is one of those giant firms, with 250 offices around North America and the world that advises government on new projects. Go on to their web site and see the gigantic hospitals they proudly have given their services to see built. I always get nervous when I find that one of these large companies are involved because I think they care little about the community they are consulting in: their job is to recommend big change and the need for a big new facility. So when Stantec says renovation isn’t possible, I tend to be skeptical about their conclusion.

Just look at what they say. In a report filed on April 5 – just this week – they say the number of beds should double from 73 to 152 in twenty years. They are not talking about a modest sized hospital, they are talking about something at least twice as big.

Then they talk about land needs.  The current hospital owns 12 acres of land, and I am sure you will have noticed that much of it is for parking, often vacant and empty. But Stantec says that’s simply not good enough even if you purchased the vacant land around it. It has recommended, and apparently the hospital board and the LHIN have agreed, that what is needed is a `Health Care Campus’, not just a hospital. That means a site large enough not just for the next 10 or 15 years, but for the next 25 to 50 years.

How do you plan for a 25 or 50 year timeframe in a hospital when advances in medicine and treatment change so quickly? Could anyone have guessed 25 years ago that hospitals would need space for out-patient daily chemotherapy treatment for cancer today? No.  Even 10 years ago few imagined that kind of treatment.

What kind of space do we need for genetic treatment? Who knows? Fifty years ago we were worried about polio, but not today. Fifty years ago we thought that two patients in a room was luxurious and that wards with four and six people were standard. Today we realize that shared bathrooms means sharing germs, and one-patient rooms are almost the standard.

Trying to plan for 25 or 50 years, and putting aside enough land to ensure we can meet whatever needs arise long after most of us are dead and buried is a mugs game. It is wasteful and useless.

 

6. What the Stantec study never mentions is the extraordinary innovation which has occurred in Collingwood. Collingwood has a strong reputation for supporting patients where they live. In fact Collingwood has one of the most developed and integrated primary care networks of anywhere in the province. It was one of the reasons why, when my mother-in-law was considering a move to Toronto, she decided to stay in Collingwood. 

Here’s an example of what I mean. An elderly congestive heart failure patient requires weekly blood work. A mobile phlebotanist (person who draws blood) does a home visit and sends the blood work to the lab. The lab sends the results to the physician electronically who notifies the pharmacy of medication changes. New medications are prepared and delivered to the patient at home.

The hospital plays a part in this, but it is not central. Good health care is taking place outside of the hospital. That obviously affects what should be built for the future – you won’t need as large a hospital.

It is these kinds of networks that will serve the aging population more effectively. As technology and service models evolve what is working for primary care networks will extend to all aspects of healthcare. We know there will always be a role for acute care. If we believe the future of healthcare lies in these distributed systems then the role of the hospital is to be but one node on the network and not a giant inflexible structure that demands the community comes to it. But that doesn’t seem to have mattered much to Stantec. It was never mentioned in the study.

When you begin with the fact that your job is to implement a big big vision then you are stuck with what Stantec recommends, a 30 acre site. Twelve acres simply won’t do, according to Stantec.

This is exactly what has happened in those other communities that now face the burden of a large hospital on the edge of town. Where else can you find such a large site except far out of town in a farmer’s field?

 

7. What is being proposed for Collingwood is the same dumb solution that has happened elsewhere, and it is because that is what the Ministry of Health wants it that way.

The process for new hospitals is for the Ministry of Health to work with local hospital authorities including the Local Health Integration Network around needs and location. The need determines what will be built and the location study will determine location.

Ministry of Health criteria  says “The Site should be large enough to accommodate the proposed uses as well as future buildings, structures, parking, landscaped garden areas, etc., including allied services and potential research uses.”

“The parcel size must plan for potential physical and site needs of the Facility over a 5, 10, 20, 50 and 100 year timeframe that ensures best use of significant and long term government commitment. It should provide flexibility to accommodate major changes in health care delivery and/or program requirements.”

Why would the provincial government have a policy which recommends that new hospitals are located in places that are not consistent with good planning or with accessible patient-centred care?

 

8. I think it has to do with the way that hospitals are built, and that involves the second Ministry, Infrastructure Ontario. After the decision is made by the Ministry of Health and local health authorities about services and location, the matter is then turned over to the Ministry of Infrastructure Ontario to build. 

Infrastructure Ontario builds hospitals and infrastructure using the Public Private Partnership model. The government says what it wants built, then asks private companies to put in bids, then signs an agreement with a private consortium which guarantees the price at which it will be designed, built, financed and in many cases the price at which it will be operated.

The triple P program was devised for two reasons. One thought was that governments can’t control costs, and that private companies are much more efficient. That is a very questionable assumption but for some it is a matter of deep belief, even faith. The Public Private Partnership model is based on this belief.

The other reason is that going the PPP route means the government does not have to make a big outlay of money to build the infrastructure. It does not have to put the money up front. Instead, the government makes annual payments for 25 or more years to cover the whole thing. It is like buying a car where they say: buy this car, we will give you $5000 in cash and you won’t have to begin making payments for another 12 months. Indeed it sounds attractive, but you are being fleeced in the long run. In the past governments would allocate the money to finance construction, then contract with a private company to build a hospital. Today the whole process is turned over to the private sector on the theory that this is `value for money.’

I think this PPP process is what drives the government to insist on large sites which are not constrained by irregular property lines or existing buildings. A PPP process wants a clean site, because that makes the bidding much simpler. I think this is unspoken, but I believe it lies behind the crazy criteria which are so much against city building.

PPPs do not save the public money: they cost money. A 2012 study of hospitals built in Ontario under the PPP model, and confirmed more recently by the Auditor General for Ontario, shows that PPPs cost 18 per cent more than if the public had gone about arranging the design, financing and construction of the hospital itself. The cost of the private sector assuming all of the risk – and I would argue the risk in building a new hospital is not substantial – is very high: 18 per cent of the cost. For a new hospital costing $250 million – which is the estimate of the new Collingwood hospital – the extra cost is about $60 million. That is a significant sum.

This process means that the Ministry of Health doesn’t really worry about money: it worries about function and location. Infrastructure Ontario just worries about getting the lowest bid for what the Ministry of Health has approved. No one really worries about how much money the government has to spend, just as no one really worries about accessible, patient-centred care or city building.

9. What we are dealing with are two crazy ideas. One is the idea of starting over. Forget about the sense of community. Forget about the existing hospitals. Forget about the fact that doctors’ offices will have to relocate and retirement homes will be a long way from hospitals, Forget about what is on the ground and just start over again. It is no different than the ideas of urban renewal in the 1960s. I helped lead the fight in Toronto against urban renewal in the late 1960s working with a neighbourhood which fought the city. The community said, instead of tearing our neighbourhood down and starting over, let’s improve and repair it. The residents won that fight. Demolition and replacement is now a discredited idea in neighbourhood planning. But this discredited idea seems to remain a central idea of the Ministry of Health for hospitals and it is wrong. 

The ministry should ask, how can we improve and add to existing hospitals to take care of today’s needs, while building space that is flexible enough to respond well to future needs? But it doesn’t. It says, we can start over and get everything right, there won’t be any problems.

We all know that those who approach the world in that blind fashion often get almost everything wrong.

Starting over is one problem. The second problem is that those running this process seem to be nice people but what they are proposing is something that would be recommended by a megalomaniac. Megalomaniac is a big word so I looked it up in the dictionary. It means “a mental disorder characterized by delusions of grandeur, wealth and power. “ That perfectly fits what is proposed here – a hospital plan couched in grandeur, wealth and power: how I wish it was couched in accessible patient-centred care and city building instead.

If you are wondering what I am thinking  of – think of the new Barrie hospital. It is grandeur personified.

The ministry says: we will build a big new facility and it will be much more efficient than the hospitals today. Those who run it will be much smarter. Wrong and wrong again. Spending money on a building never resolves the long-standing issues of human behaviour.

The thought that if we build the right facility then all the human problems will be solved is a delusion. Every cent spent in building with concrete and mortar is money that cannot be spent on people providing accessible patient-centred care. It is money that will be lost to good health care.

10. Let me be really clear. Stantec and the hospital board and the Ministry are heading in exactly the wrong direction. They don’t seem to care much about patient centred care, they don’t seem to care about the existing community. I don’t think they care much about public money. They estimate the cost of the new hospital for Collingwood at $250 million, but I am sure the cost will be higher once they get to building it. That cost does not include the substantial infrastructure costs which the town will be required to provide for roads, water and sewage on the edge of town, costs you will be forced to pay for in your property tax.

There is a more realistic scenario which would provide better health care for the community, and which would strengthen, not weaken the town’s economy, and that is to consider adding to the existing structure, keeping some of the existing structures for administrative services. Currently, half the space in the hospital is used not for clinical programs or services, but for administrative support which does not require anything high technology for medicine, or any design to ensure infections are minimized.  It is just office space.

Even using Stantec’s numbers for 20 years from now, the estimate for total space needed for clinical support and services is about 200,000 square feet, and that includes the hefty bonus of 40 per cent which Stantec wants to factor in for reasons that I am not aware of. A three  storey building of  200,000 gross square feet would occupy less than two acres.

 

11. Let me repeat that:  A three storey building of 200,000 gross square feet would occupy less than two acres. That building could easily fit on the existing parking lot to the east of the existing hospital.  This is not rocket science. It is common sense. It is called approaching the problem without stars in our eyes.

So even if everyone agrees that new facilities for clinical programs and services are needed, those new facilities can easily be slipped onto the existing parking lot. There would be no need to disturb the existing array of doctors’ office and retirement homes nearby. There is no need to tear down a single house. A central location serves the most patients and the most staff. If the objective is to provide accessible patient-centred care, a central location is always best.

There is adequate land right there, providing one is talking about sensitive architectural design and being modest about the size of the facility.

12. Here are the challenges for Collingwood.

A. Location.  It is good that Collingwood town council has indicated to wants the hospital to remain where it is, and will provide funding if that happens. That’s a powerful start to the process – but it is far from conclusive: we need to get the Hospital Board and the Local Health Integration Network to agree, and then the Ministry will be much more likely to agree.

B. We need agreement that the hospital will be built on land already available, such as the large parking lots to the east and north of the current hospital. Council should not designate any houses to the wets fo the current hospital for health care purposes. Houses to the west should not be threatened with expropriation and demolition for any reason, certainly not for parking. This will take some change on the part of Town Council, which seems ready to designate this land for hospital purposes.

C. We need agreement that if there is to be a new facility, that the result will be something modest. No one needs a big elephant of a building, such as they have in Barrie or Owen Sound. Hospitals of the future should not be larger, they should be smaller as we work out ways for people to live at home and die at home, as procedures like hip replacements happen in a few days and not a few weeks. We need flexible space not specialized space since we don’t know what we will need in ten years, given the rapid change in technology and medical practise.

D. We need a really well designed hospital, something which is a pleasure to visit and to be in and which is fitting for Collingwood. Something which is elegant and attractive, since those are qualities which help the healing process. That means hiring an architect to work with rather than passing it over to a financier to design. This will need lots of support to secure.

E. We do not need a PPP, public private partnership, which has shown to be so expensive, and is often beyond the control of local leaders. Building things in the same manner as the women built the first hospital here more than 120 years ago is probably the right model to follow: get a plan, put it out for bid, and then select the best construction company to build it. It is a device which has worked well for centuries.

F. We need to ensure there are reasonable funds for operating the new or the improved and expanded facility. Current funding for smaller hospitals is always frozen, and there simply isn’t the kind of flexibility in smaller hospital to function well when they are not even allowed to keep up with inflation. Working with the Ministry of Health on a revised annual funding formula can be helped by showing that the cost of what you want to build is modest, not the $250 million plus which is projected. I would argue that you decide on a capital budget of $100 million to work with, for renovation and new construction, and then propose an extra $5 million a year for increased operating costs, increasing by $1 million a year for ten years.  That saves a lot of taxpayers money.

Many other communities share the same concern about the funding formula, and you should work with them, creating new financial frameworks for talking with the government since the current ones don’t seem to work, and the government doesn’t respond well to local complaints.

13. These six tasks need more than the attention of town council, the hospital board and the LHIN, particularly since the hospital board and the LHIN seem headed in the wrong direction. These tasks need a group of active residents willing to be creative and think outside of the box.

 

Perhaps the place to begin is with is a modest study which looks at the physical resources do we need, and the human resources we need to improve health care here. Is renovation and expansion reasonable, or is a new structure for clinical services the only possibility? If it is a new structure, how do we ensure it is modest, well designed by a first class architect, and fits well on existing land owned by the hospital and used for parking? And part of the deal must be to ensure adequate annual operating funding for the nurses, orderlies, cleaners, doctors and other support staff needed for a great moderate size hospital.

A strong group of dedicated citizens who will engage on all these questions to ensure the answers are convincing and reasonable is clearly needed. I have brought some sign in sheets for those who wish to be part of such a steering committee which I am willing to pull together and get working in a co-operative and friendly manner.

In conclusion, Collingwood has the chance to get it right in planning a new and/or improved hospital that works well for this community for the next 20 or 30 years. But it will take some work to achieve that outcome, since the way new hospitals have been planned in the past in communities this size is not something we want to happen here.

Let me end at the start. The founding story is usually a determining factor for any organization. The way the organizations started is often the best way for it to continue to evolve. Collingwood hospital started by a groups of citizens – women – getting together to plan for a hospital. The powers that be – Simcoe County Council – told the women they were wrong for three years. The women continued with their vision and established the hospital, and then County Council finally realized the women were right. That’s the founding story of the hospital and it is why a strong group of citizens is needed now as the hospital evolves.